So Thomas Edison isn't to blame after all, and the best sleep medications may just make us think we had a good night's sleep (not that they ever worked for me, anyhow...)
November 18, 2007The Sleep-Industrial Complex
By JON MOOALLEM
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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.”At Day’s Close, described just how frenetic night in preindustrial times was. People slept, or tried to, in poorly insulated buildings that let in the weather and noise. Livestock huffed and mewled and stank just outside — if not inside. Generally, you slept beside a chamber pot of your own excrement, staggering across the room every few hours to keep your fire alive. With physical health comparatively poor, night was when people simmered most acutely in their discomfort. In 1750, one writer described London between the hours of 1 a.m. and 2 a.m. as a ghastly encampment of “sick and lame people meditating and languishing on their several disorders, and praying for daylight.” Because there was inadequate bedding, if there were beds at all, three family members and the odd houseguest might sleep on a single mattress — sharing in all the usual annoyances of tossing, blanket-hogging and snoring. Beds were not always, or even often, seen as having much impact on sleep. Another book, Warm and Snug: The History of the Bed, by a scholar named Lawrence Wright, suggests that they were valued primarily as furniture, settings for public rituals around birth, death and courtship. Beds did raise you up off the floor, away from the bugs and vermin, and kept you warm. But warmer bedding also created a new vector for mites. And when comfort was a consideration, preferences were just as idiosyncratic as today. Mattresses were stuffed with hair, moss, feathers, wood shavings, seaweed or straw. Louis XI had an uncannily Sleep Number-esque mattress, filled with air and inflated to his liking with a royal bellows. More surprising still, Ekirch reports that for many centuries, and perhaps back to Homer, Western society slept in two shifts. People went to sleep, got up in the middle of the night for an hour or so, and then went to sleep again. Thus night — divided into a “first sleep” and “second sleep” — also included a curious intermission. “There was an extraordinary level of activity,” Ekirch
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,
told me. People got up and tended to their animals or did housekeeping. Others had sex or just lay in bed thinking, smoking a pipe, or gossiping with bedfellows. Benjamin Franklin took “cold-air baths,” reading naked in a chair.
Our conception of sleep as an unbroken block is so innate that it can seem inconceivable that people only two centuries ago should have experienced it so differently. Yet in an experiment at the National Institutes of Health a decade ago, men kept on a schedule of 10 hours of light and 14 hours of darkness — mimicking the duration of day and night during winter — fell into the same, segmented pattern. They began sleeping in two distinct, roughly four-hour stretches, with one to three hours of somnolence — just calmly lying there — in between. Some sleep disorders, namely waking up in the middle of the night and not being able to fall asleep again, “may simply be this traditional pattern, this normal pattern, reasserting itself,” Ekirch told me. “It’s the seamless sleep that we aspire to that’s the anomaly, the creation of the modern world.” In fact, many contemporary, nonindustrialized cultures contentedly pass portions of the night in the same state of somnolence, says Carol Worthman, an anthropologist at Emory University who is one of the first to look at how other societies sleep. Sleep and wakefulness are rarely seen as an either/or, but rather as two ends of a wide spectrum, and people are far more at peace with the fluidity in between. Among the Efe in Zaire, and the !Kung in Botswana, for example, someone who wakes up in the middle of the night and cannot sleep “may begin to hum, or go out and play the thumb piano,” Worthman and a colleague have written. Others might wake up and join in. “Music or even a dance may get going.”
Worthman says, “In our culture, quality sleep is going into a dark room that is totally quiet, lying down, falling asleep, doing that for eight hours, and then getting up again.” She calls it the “lie down and die” model. “But that is not how much of the world has slept in the past or even sleeps today.” In some cultures sleep is more social, with crowds crammed together on little or no bedding, limbs entangled, while a steady traffic comes and goes. And while it all sounds unbearable, Worthman notes that science has never looked empirically at whether our more sophisticated arrangements actually benefit us. For children, learning to sleep amid all that stimulation may actually have developmental advantages.
Still, we can’t afford the same equanimity about not sleeping through the night as the Efe and !Kung; the flipside is that men and women in those cultures are content to pull a cloth over their faces and doze off during the day if necessary. Our peculiar preference for one well-organized hunk of sleep likely evolved as a corollary to our expectation of uninterrupted wakefulness during the day — as our lives came to be governed by a single, stringent clock. Eluned Summers-Bremner, author of the forthcoming Insomnia: A Cultural History, explains that in the 18th century, “we start overvaluing our waking time, and come to see our sleeping time only as a way to support our waking time.” Consequently, we begin trying to streamline sleep, to get it done more economically: “We should lie down and go out right away so we can get up and get to the day right away.” She describes insomniacs as having a ruthless ambition to do just this, wanting to administer sleep as an efficiency expert normalizes the action in a factory. Certainly all of us, after a protracted failure to fall asleep for whatever reason, have turned solemnly to our alarm clocks and performed that desperate arithmetic: If I fall asleep right now, I can still get four hours. Nevertheless, while it may be at odds with our history and even our biology, lie-down-and-die is the only practical model for our lifestyle. Unless we overhaul society to tolerate all schedules and degrees of sleepiness and attentiveness, we are stuck with that ideal. Perhaps the real problem is that we still haven’t come to terms with the unavoidable imperfection of this state of affairs.
Electric light didn’t obliterate nighttime so much as reinvent it. Our power to toggle between light and dark encouraged us to see night as an empty antithesis to day — an unbroken nothing-time that begins the instant we flip off the switch. And this significantly reshaped and rigidified our expectations of how we ought to be spending it. All of this leaves us — regardless of the circumstances or how poor our sleep hygiene is — insisting that we go out, and stay out, like a light. Our expectation of perfect sleep may not always be biologically feasible. But it is indisputably reasonable, and thus a failure to fulfill it can be maddening. Difficulty sleeping, it turns out, is often inseparable from and heightened by anxiety about sleep itself.
Charles Morin, the Laval University psychologist, told me that it’s not uncommon to discover that a particularly implacable case of insomnia snowballed out of a single stretch of poor sleep — even one with a clear, unavoidable cause, like stress over a new job. While most people eventually shrug off their trouble, the insomniac “forgets what brought about the sleeping problem in the first place,” Morin said. “They worry about not sleeping and how it will impact their daytime functioning, and they start to do things that make sleep more difficult.” They take naps, throwing their schedule out of whack. Or they become too determined — Morin described patients taking a bath or getting into their pajamas at 7 o’clock, “just to get ready” — and that anticipation turns into performance anxiety. Lying there, they may monitor their progress too vigilantly or worry about the ramifications the next day of not falling asleep right away. This can produce a physiological reaction. Body temperature and blood pressure rise. Metabolism speeds up. Heart rate and brain waves quicken. In other words, the body can respond to the threat of not getting a good night’s sleep the same way it does to most threats: by becoming hyperaroused. “It’s a vicious cycle,” Morin said. Those who get snared in it may share an unknown, physiological predisposition to insomnia. But whatever its cause, this feedback loop of agony, effort and failure plays out like an escalation of the kind of self-sabotage we’ve all probably experienced when we felt pressure to sleep well and be sharp the next day. “Most of the beliefs these people develop and strategies they employ are very logical and sensible,” Jack Edinger, a psychologist at Duke University and the V.A. Medical Center in Durham, North Carolina, told me. But “unlike most things in life where, the harder you try, the better you do, with sleep the harder you try the worse you do.”
Edinger and Morin have been influential in the use of cognitive behavioral therapy, or C.B.T., to treat chronic insomnia. Studies have arguably shown it to be the most successful treatment for the problem and an astonishingly effective method of weaning insomniacs from sleeping pills — even those who have taken them every night for decades. C.B.T. Therapists work to establish good sleep habits but also to rewrite an insomniac’s unhelpful beliefs about sleep. One of the most typical and debilitating ones, Morin explained, is “that eight hours of solid, uninterrupted sleep is a must every night — and otherwise, without it, you can’t function during the day.” Fixating on that as a requirement only undoes a person. Besides, Morin added, a universal need for eight hours is simply “untrue.” This is exactly the kind of admission other sleep experts I spoke with seemed not to want to make. They may worry that they’ll cause people to take sleep even less seriously than they already do. But C.B.T. seems to succeed by stripping away a crippling sense of urgency with respect to sleep. How powerless one feels over the quality of his sleep; how realistic his expectations; and whether he exaggerates the consequences of sleeping poorly — these have all been shown to correlate with the severity of an insomniac’s complaints. Morin has developed a scale to measure these beliefs. In a study utilizing this scale and led by Edinger, a person’s score emerged, with other measures of anxiety and mood, as a better predictor of his satisfaction with a night’s sleep than objective measures made in the lab — including how long he slept and how quickly he fell asleep. In fact, these objective measures didn’t seem to correlate to people’s sense of how well they slept at all. Because sleep deprivation may exact a host of severe tolls on the body over time — which is to say nothing of exhaustion-related car accidents and other dangers — Edinger warns that there are people with appallingly disturbed sleep who “roll with the punches a little better and don’t seem to mind or complain — but maybe they should.” Still, C.B.T. suggests that, in certain cases, creating a purely subjective satisfaction with your sleep can have actual value, even if the sleep itself hasn’t yet objectively improved. While undermining the appeal of sleeping pills by positing the self-evident seeming role of amnesia, Morin noted that C.B.T. tries to foster a kind of amnesia, too. “After a poor night of sleep we’re asking people to forget about it and go about their business as usual,” he says. “Because if you wake up and think, Wow, what a terrible night of sleep, I’m going to have a lousy day, you’re setting yourself up for failure.” This is not to say that a person who is more tolerant and less threatened by sleep’s inherent imperfections will suddenly get eight uninterrupted hours. But he might be less likely to start down that long, miserable road of perfectly sensible but damaging efforts to control sleep. And that could trigger a quantifiable improvement. If he establishes good habits and puts sufficient faith in his body to get the job done, he might stop trying, stop scrutinizing his progress and thereby stop perpetuating his own hyperarousal. He’d just lie there and wait. “The placebo effect may actually not just be a placebo,” Morin said. “It may produce a physiological predisposition to better sleeping.”
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If ramping up messages about sleep science and technology while bombarding us with medical incentives helps sell more beds, it will be because it speaks to our view that better sleep is primarily a requirement for better wakefulness — that we “sleep to succeed,” as a recent industry-financed release puts it. (This same report notes that “sleep deprivation currently costs U.S. businesses nearly $150 billion annually in absenteeism and lost productivity.”) And yet it’s this very view — that sleep is a bothersome means to an end, like eating enough Omega-3’s — that problematized sleep in the first place. It encouraged us to power through sleep as efficiently as possible or look for shortcuts.
We all might be better off if the industry sold sleep as something to be savored for its own sake, if it just sold sanctuaries and not sanctuaries that are also clinically proven “sleep systems.” That might help us shed an anxiety about sleeping correctly for a more tolerant love of sleeping well, in whatever form sleeping well might take. Oddly, in some cases, that may be the most efficient way of getting empirical results anyway. That is, the industry may only be able to truly offer the kind of life-changing mattresses it sometimes claims to if it fixes the people sleeping in them first.
Monday, November 19, 2007
maybe you can catch some zzs from reading this
okay, ever obsessed with sleep (or rather the lack thereof) i found the following New York Times article to be of more than a little interest) I tried to cut a bit of its rather extreme length but i just found it ever so intriguing: