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For years, doctors have been discouraged by Americans’ disregard for and mismanagement of their sleep. (“I might as well have been running a chain of beauty parlors for the last four decades” is how one described his advocacy.) But bragging about how little you sleep, a hallmark of the ’80s power broker, is starting in certain circles to come off as masochistic buffoonery. The sleep docs we once ignored appear on morning shows to offer tips. Health professionals and marketers are hopeful that a new seriousness about sleep will continue moving out of a luxury-minded vanguard and into the mainstream. Sleep may finally be claiming its place beside diet and exercise as both a critical health issue and a niche for profitable consumer products.
A sleep boom, or as Forbes put it last year, “a sleep racket,” is under way. Business 2.0 estimates American “sleeponomics” to be worth $20 billion a year, which includes everything from the more than 1,000 accredited sleep clinics (some of them at spas) conducting overnight tests for disorders like apnea, to countless over-the-counter and herbal sleep aids, to how-to books and sleep-encouraging gadgets and talismans. Zia Sleep Sanctuary, a first of its kind luxury sleep store that I visited in Eden Prairie, Minn., carries “light-therapy” visors, the Zen Alarm Clock, the Mombasa Majesty mosquito net and a $600 pair of noise-canceling earplugs as well as 16 varieties of mattresses and 30 different pillows.
Prescription sleeping pills have been the most obvious beneficiary. Forty-nine million prescriptions were written last year, up 53 percent from five years ago, according to IMS Health, a health-care information company. It is now a $3.7 billion business, more than doubling since 2003. At $3 or $4 per pill, their success indicates not only that we have an increasingly urgent craving for sleep but also that many of us have apparently forgotten how to do it altogether — quite a feat for any mammal.
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All good nights of sleep are alike. Each miserable night of sleep is miserable in its own way. You either close your eyes and, many hours later, open them, or you endure an idiosyncratic epic of waiting, trying, failing, irritation, self-sabotage and despair, then stand up at sunrise racked with war stories you don’t have the energy to tell.
Sleep research is a young field and still doesn’t have a definitive picture of what “normal” sleep is, making discussions of abnormal sleep imprecise. The National Institutes of Health can define insomnia only very broadly, as “complaints of disturbed sleep in the presence of adequate opportunity and circumstance for sleep.” Insomnia can be transient — a few off nights — or horrifically chronic. Complaints may be about difficulty falling asleep or about waking up during the night. But it’s hard to know exactly what those complaints should be judged against. Nor has research determined which objective measures — total time slept, percentage of time spent in the various stages of sleep, etc. — correlate to a person’s subjective feeling of having slept well or poorly. Some people whose sleep looks normal in the lab complain bitterly; some whose sleep looks terrible never do.
Even something as empirical-seeming as how long we sleep becomes problematic. In studies, insomniacs almost invariably overestimate how long it took them to fall asleep and underestimate how long they slept; in one, more than a third of the participants consistently thought they’d slept at least an hour less than their brain-wave activity indicated. Yet in a way, this hardly matters. Wallace Mendelson, past president of the Sleep Research Society, explained to me, “When a patient comes to a doctor, he doesn’t say, ‘I’m here to see you because my EEG shows an insufficient number of minutes of sleep.’ He comes to you saying: ‘I don’t feel like I’m getting enough. I’m tired.’ ” Thus, while insomnia is frequently linked to another, distinct physiological disease or disorder, its diagnosis and treatment often remain, much like pain, locked in the realm of our own inscrutable reports.
Fewer than half of Americans say they get a good night’s sleep every night or almost every night, according to a 2005 poll by the National Sleep Foundation. The N.S.F. is a nonprofit largely financed by the pharmaceutical industry and one of many groups — including the American Academy of Sleep Medicine and the Better Sleep Council, a nonprofit supported by the mattress industry — that have pushed the value of sleep, and the perils of sleep deprivation and disorders, into public view. (You can mark the change in seasons with their press releases. End of summer: “From Zzzs to A’s: Healthy Sleep Is Key for Back-to-School Success.” Daylight Savings Time: “Fall Back Into Bed and Catch Up on Your Sleep.”)
Some of America’s dissatisfaction likely boils down to poor “sleep hygiene” — basic bad habits like not keeping a regular bedtime; overconsumption of alcohol or coffee; or winding ourselves up with work or television before bed. There is a sometimes-stunning failure to see sleep’s cause-and-effect relationship to what we do while awake. One therapist told me he cured a man’s insomnia by suggesting he stop eating spicy Indian curry late at night. Bils says, “Most sleep problems are self-inflicted by sleepers not knowing how to sleep.” Moreover, doctors have long warned that Americans are suffering from self-caused sleep deprivation without even realizing it. The most damaging and persistent delusion we’ve acquired about sleep is that the vital human function is optional. As one psychologist puts it, “You don’t have people walking around figuring out how to get by on less air.”
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$4.6 billion spent on mattresses. Their staying power and overt sciencey-ness had colossal ripple effects on the entire industry. Jim Gabbert, the second-generation mattress retailer behind Zia Sleep Sanctuary, explains: “At first everyone saw air and visco as a fad, like water beds. ‘It won’t amount to much.’ Now all the mainstream innerspring manufacturers are scrambling to compete with those guys.
Those specialty manufacturers taught the mainline brand names that you can price things higher, add more features, have a better story.” The big question became, what else might Americans sleep on — and what combinations of things? The S-brands rolled out their own memory foam beds. Latex foams, modestly successful for decades, also came into vogue — as did various gels. Meanwhile, the industry was finally breaking down the wives’ tale that firm mattresses are always better. “Comfort” became the new buzzword, freeing manufacturers to combine all their new, high-tech materials in infinite iterations on a single bed. Pillowtops, distinct slabs of cushy material stitched on the tops of mattresses, gradually thickened, and beds ascended skyward, layer by layer, in towers of trademarked babble. Serta offers KoolComfort foam. Simmons makes Natural Care Latex and, via its brand ComforPedic, NxG Advanced Memory Foam. Having muscled their way into a virtual stalemate of technology inside the mattress, manufacturers seem to have merely started their arms race all over again on top of it. The end result may not be much better; rather than seeing beds as all the same, consumers are often totally incapable of understanding their countless differences. “It does get confusing,” says Brandon Jackson, bedding director at Houston’s Gallery Furniture store. “After a while, those layers are really only there to add to the cost.” When Jackson started six and a half years ago, selling a $1,000 mattress was “a home run.” Now his average ticket is $3,300.
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The message, I suppose, behind so many of the mattress industry’s claims is that all of a bed’s high-tech features should combine to create nothing at all — a space free of any impediments to sleep whatsoever. Even the message of the Sleep Number Bed itself, with its two independently inflatable halves, was that your sleep should not be compromised by the adversarial preferences for firmness of the person you love. Now the mattress would shield you from your own body heat, free you from rolling over and end the Sisyphean cycle of flipping and reflipping your sizzling pillow. The industry was clearing the decks for that big, long nothingness to take hold.
Even the most comfortable mattress can only create a place for sleep, not manufacture it directly. But a sleeping pill puts us down — and under circumstances when we’re unable to do it ourselves. Bils told me: “The sleeping pill is an easy path. It promotes sleep over all the rules you break.” In trying to deride his competition, he spelled out its greatest advantage.
Pharmaceutical companies realize they are selling a reassuring guarantee. “Does your restless mind keep you from sleeping?” asks one Lunesta commercial, while the green moth floats in front of a tossing man. Suddenly, like a hypnotist’s watch, it dispatches him into a deep slumber and flies on to lull even the stern, stone visages of Mount Rushmore to sleep. A couple in a commercial for Ambien CR, meanwhile, lie absolutely motionless all night until the darkness around them fades to daylight.
Last year the industry spent more than $600 million on advertising, helping the newest generation of pills, the so-called “Z drugs,” destigmatize sleeping-pill use. The nation’s most popular, Ambien and its extended-release counterpart Ambien CR, accounted for 60 percent of all sleep-aid prescriptions last year according to IMS Health, for $2.8 billion in sales. Surely great numbers of Americans are experiencing the kind of satisfying knockouts depicted in the commercials.
Yet, as a very infrequent but contented user of both Lunesta and Ambien myself, I was startled to read efficacy trials for those drugs submitted to the F.D.A. In one six-week trial, for example, people taking Ambien every night fell asleep, on average, only 23 minutes faster than those taking the placebo. They spent 88 percent of their time in bed asleep, as opposed to 82 percent. Given that their objectively measured improvements are frequently this meager, why do sleeping pills create incommensurate feelings of having slept so well? A popular theory is that one of the pill’s side-effects is actually contributing to their success. Most sleeping pills are known to block the formation of memories during their use, creating amnesia. This is why people who endure freaky side-effects — so-called “complex sleep-related behaviors” like getting into a car and driving or ravenously eating, all while asleep — don’t remember those events. Yet this amnesia could be quite beneficial, suggests Michael Bonnet, a professor of neurology at Wright State University Boonshoft School of Medicine in Dayton, Ohio. “How do you know you slept last night?” Bonnet asked me. A night of lousy, interrupted sleep, he points out, is easy to remember. “It’s full of memories, noise and pain, and heat and rolling around and obtrusive thoughts and worries — all of these various stimuli.” And we may continue to register such things even while asleep, making sleep vaguely unrefreshing. But a good night of sleep, Bonnet went on to say, “is always the antithesis to all those things, which is oblivion.” A sleeping pill, Bonnet speculates, in addition to encouraging sleep chemically in the brain, also “erases all of these thoughts that we use to define ourselves as being awake. The pill knocks them all out, and the patient says, ‘Hey, I must have been asleep because I don’t remember anything.’ ”
Drug-company representatives and consultants I spoke to confirm that their pills can create this mild form of amnesia but disagree that it contributes any significant benefit. “That is not my understanding of how Ambien works,” Dario Mirski, a psychiatrist and spokesman for Ambien’s manufacturer, Sanofi-Aventis, told me. It is difficult to find a clinical trial in which Z-drug takers drastically overestimated how long they slept. Andrew Krystal, a Duke University psychiatrist and consultant to pharmaceutical companies like Sepracor, Lunesta’s manufacturer, acknowledges an apparent discrepancy in studies between small, objectively recorded improvements and the large percentage of subjects who end up feeling that a pill alleviated their insomnia. But because insomnia is complaint-based, he explained to me, an insomniac is cured when he stops complaining. Who’s to say how many more minutes of sleep or fewer awakenings during the night it should take to relieve each individual’s highly subjective dissatisfaction? Many insomniacs don’t show impaired sleep by any objective measure to begin with — but presumably they benefit from sleeping pills, too. So, Krystal asked, what would you expect to see improve? (A 1990 study presents a jarring example: it focused on a group of insomniacs who, when woken up, swore they hadn’t been sleeping. But if given a sleeping pill first, then woken up, they knew they’d been asleep.) He added, “I’m not a person who shares the view that the reason the drugs work is because they’re amnestic.”
Another prevalent theory is that sleeping pills produce a beneficial physiological effect that clinicians don’t realize they should be measuring. The standard battery of brain-wave and other measurements used in sleep labs provide only a “limited picture,” Krystal said. Nevertheless, several researchers suggested why the amnesia factor isn’t likely to be explained to patients, even as a theory. We tend to see sleep problems as physiological. A treatment that works, even in part, by altering our perception of that problem would seem like “more of a fake,” says Charles Morin, director of the Sleep Research Center at Laval University in Quebec City. Imagine, Morin said, if doctors told their patients: “You keep waking up at night but you just don’t remember it.”
Sleep doctors have criticized sleeping-pill ads for setting up an unattainable expectation of how blissful and easy sleep should be. But the mattress industry operates under that expectation, too, trying vigorously to build a state-of-the-art, NASA-engineered arena on which that idealized, paralytic oblivion can occur. But how did we come to need so much help sleeping in the first place, and how did we come to want, much less expect, the sleep these people are selling?
The story of our ruined sleep, in virtually every telling I’ve heard, begins with Thomas Edison: electric light destroyed the sanctity of night. Given more to do and more opportunity to do it, we gave sleep shorter and shorter shrift. But the sleep that we’re now trying to reclaim may never have been ours to begin with. “It’s a myth,” A. Roger Ekirch, a professor of history at Virginia Tech, told me. “And it’s a myth that even some sleep experts today have bought into.”
Ekirch’s 2005 book,
for herself and you can also see why there might be a bit of a real romance for her and the Danish prince (he's not quite as wishy-washy as some have played him, either.) Some stuff that i was thinking sounded a bit like another Shakespeare plot was explained slightly (if a bit too cutely, pertly, patly, etc) at the end.
