Medicalization And De-medicalization Of Sleep And Its Impact On Treatment

Medicalization and De-medicalization

Scholars of the medicalization of the prevailing social problems often fail to analyse the multiple directions of medicalization and level of analysis. In the majority of the cases, they conceptualize medicalization as a category rather than a continuous process. They also fail to identify the threshold at which the given process becomes “medicalized” or “de-medicalized” (Halfmann, 2012). In relation to both the reasons, the scholars frequently miss the instances of medicalization, especially de-medicalization. They also fail to recognise the moments when both the events occur simultaneously (Halfmann, 2012). According to Moloney, Konrad and Zimmer (2011), sleeplessness or inability to sleep or insomnia is characterised as an epidemic at present, an unmet public health concern. The following essay aims to analyse how medicalization and de-medicalization co-exist under the context of sleeplessness or sleep disorders. In doing so, the essay will also discuss, the role of sleep apps in medicalization of sleep and its usefulness in treating sleeping disorders. The analysis of this topic is crucial because chronic sleep deprivation increases the risk of other mental health complications and decreases job productivity. Thus, analysing the impact of medicalization and de-medicalization on the prospective treatments for sleep deprivation is important.

Medicalization deals with defining a problem by the use of medical terms and use of medical language in order to describe a problem or adoption of medical interventions or framework in order to solve the problem. Most often medicalization is defined as a socio-cultural process that may or may not deal with the medical profession or result in the intentional expansion by the medical profession for medical treatment. Alternatively, Moloney, Konrad and Zimmer (2011) highlighted that medicalization is the process under which formerly normal biological processes of behaviours come to be accepted or described or is treated as medical process. The overall process value is neutral but outcomes might affect public health. De-medicalization is obverse of medicalization (Halfmann, 2012).

Williams (2004) stated that sleep is a neglected topic under the sociological perspective. However, past and present references have suggested that sleep has socio-logical significance in relation to how, when and where a person sleeps. The importance of sleep in normal functioning of life under the context of the spatio-temporal arrangements drives in significance of the concept of medicalization and sleep. In relation to medicalization of sleeplessness, as a public health concern, Moloney, Konrad and Zimmer (2011) conducted an analysis in sleeplessness, complaints of sleeplessness diagnosis and subsequent prescriptions of sedatives hypnotics on physicians’ office visits during the tenure of 1993 to 2007 in the United States. The authors mainly used annual data from the National Ambulatory Medical Care Survey (NAMCS), national representative survey of US office-based physicians visit conducted by the National Center for Health Statistics (NCHS). The analysis of the results highlighted that there is a strong disparity between the rates of sleeplessness complaints and insomnia diagnosis in comparison to a rapid increase in nonbenzodiazepine sedative hypnotics (NBSHs) use. The NBSH prescriptions increase 21 times rapidly in comparison to sleeplessness complaints and 5 times more rapidly in comparison to the diagnosis of insomnia. This suggests that the subsequent life problems are treated with medical solution without judging the benefit of the overall formal complaint or diagnosis. If there were a tandem increase in the diagnosis and treatment or significant increase in the diagnosis alone then it would have suggested a greater prevalence of discrete disease state (Moloney, Konrad & Zimmer, 2011). The trend suggestive in the medicalization of the sleeplessness is age. Middle-aged and younger adults lack change in sleep patterns. However, they outpaced people who are aged 65 years and above and older adults who are on sleeplessness-associated measures excluding benzodiazepine prescription. According to Buffel and Bracke (2018), sleep problems seem to be medicalized when it restricts the older adults from engaging in daily living activities, as medicines are used to overcome such conditions. 

Medicalization of Sleeplessness

Increase in the level of sleeplessness among the younger adults and middle-aged adults are mainly responsible for non-biological issues like stress, use of technology. This non-biological cause of sleepless has helped to de-medicalized the concept of sleeplessness. However, it has also targeted the marketing of sleeping pills (Moloney, Konrad & Zimmer, 2011). Previously, sleeplessness complaints were associated with diagnosis of mental health complications (Taylor et al., 2013). Increased awareness between mental health illness and its co-relation with insomnia has lead the topic of sleeplessness to be de-medicalized further. (Kompier, Taris & Van Veldhoven, 2012). Huedo-Medina et al. (2012) stated that NBSHs are comparatively costly but are less addictive than benzodiazepines. However, studies conducted by Huedo-Medina et al. (2012) highlighted that NBSHs increase the overall sleep time by only 12 minutes on an average and is also associated with numerous side-effects like sleep eating, short-term amnesia, sleep walking and sleep driving. Huedo-Medina et al. (2012) reported that NBSH is risky for the patients who are under multiple medications or have previous history of substance abuse and mental illness or chances of encountering accidental falls (common among older adults). Highlighting the side-effects of sleeping pills helped in de-medicalization of the sleeplessness. It is now, treated as the state of mind which is mainly influenced by stress or anxiety.

Advent of the sleeping apps found in smart phones is another reason behind the medicalization of the sleepless or sleeping disorder. Bhat et al. (2015) conducted a study in order to analyse clinical role of the sleeping apps of smartphone in treating sleep deprivation. They selected 22 volunteers with no previous diagnosis of insomnia or sleeping disorder to undergo an in-laboratory polysomnography (PSG) while simultaneously using sleep app. The analysis of the study highlighted that there is no significant co-relation between the parameter of the sleep app and PSG. Thus, indicating the sleep app is not a true measure to ascertain the level of sleep or any impending sleeping disorders (Bhat et al., 2015). In relation to the seeping app, Van den Bulck (2015) stated that vibrating alarm from one smart-band (wearable devises) wakes up the wearer not at a pre-arranged hour but at a time when the wearer is in a state of light sleep rather than deep sleep. The manuals of such apps claims that this helps to awaken the wearer with a refreshed state of mind rather than feeling sleepy. Van den Bulck (2015) is of the opinion that getting awaken even at light sleep leads to incomplete sleep and this hampers the quality of life along with sleep deprivation. However, these apps with an aim to grab the attraction of the buyers, take help from the imagination of the developers to devise such apps which has no scientific correlation with the sleep-awake cycle (Van den Bulck, 2015). Van den Bulck (2015) further highlighted that the advent of more sleep app leads to the medicalization of sleeplessness and leading to an increase in the use of sleeplessness pills. However, the study conducted by Fleishman (2012) highlighted a sweeping generalization, which says that sleep is unnecessarily “medicalized” while ignoring the significant consequences of insufficient sleep. However, it is the role of the doctors to properly diagnose patients who have suspected sleep deprivation and provide them with effective medication.

De-medicalization of Sleeplessness

In relation to the improvement of the sleep patterns, Freeman et al. (2015) conducted a clinical trial over patients with persistent delusions and hallucinations. Freeman et al. (2015) mainly used cognitive behavioural therapy as non-pharmacological interventions for the improvements of the sleep patterns. The analysis of the results highlighted that almost 80% of the selected group of population benefited from these non-pharmacological interventions, for at-least 6 months of completion of the treatment with no known side-effects. This study helped to provide an alternative to pharmacological interventions in improvement of insomniac condition. Irish et al. (2015) are of the opinions that sleep hygiene practices like healthy diet plan, mild to moderate physical activity and restriction of the use of alcohol and tobacco can help to counteract sleep deterrents like artificial lights and 24-hour access to internet. Wolever et al. (2012) highlighted that prevention of occupational stress and proper implementation of job sharing, flexible timings at job and observance of sleep hygiene school curriculum can be helpful in decreasing the societal burden of sleeplessness.

In relation to the sleep deprivation, Hislop and Arber (2003) conducted a study in order to study the neglected area within sociology and illness that is sleep. They mainly explored the extent to which the medicalization and healthicization helps to design proper model for understanding and managing the sleep disruption in women. The analysis of the results highlighted that prescription of sleeping pills remains as an indicator for the medicalization of sleep while healthicization of sleep was a trend towards healthy lifestyle practice and the same is being reflected with an increase focus of the media and pharmaceuticals and healthcare services. The results also indicated self-directed personalized activity plays an important role in women’s response to sleep deprivation. Hislop and Arber (2003) proposed alternative model for the management of women’s sleep and this mainly include personalized activity and other linked strategies associated with healthicization and medicalization. The advent of the non-pharmacological interventions for treating sleeplessness or insomnia promotes the de-medicalization of sleeping disorders. In spite of the importance of the non-pharmacological interventions in managing sleeplessness, the sleeping pills are preferred treatment of choice by the physicians and this choice is mostly influenced by the market pressure, time constraints and increase rate of consumerism among patients. Thus, health promotion and training must be given so that the awareness among the doctors’ increase, in the domain of long-term deleterious health effects of sleeping pills and importance of the application of the behavioural therapies towards treating sleeplessness (Kornfield et al., 2015). This awareness will lead to the promotion of healthy sleeping patterns with no use of significant medication and this will further help in de-medicalization of sleeplessness.

Conclusion

Thus, from the above discussion it can be concluded that medicalization and de-medicalization are the most alarming social problems and the condition is extremely significant when it is used in relation to sleeplessness or insomnia. Sleep deprivation or sleeplessness though a neglected topic under the sociological perspective but can cast immense impact on the daily health and well-being of the individual. The medicalization of the sleep deprivation has occurred due to increase in the use of sleeping pills like nonbenzodiazepine sedative hypnotics (NBSHs). However, use of these medications has no significant effects on improving the overall sleep cycle of an individual. On contrary, it is associated with numerous complications and side-effects in the long-term. Moreover, the sleeping apps are also responsible for medicalization of sleep. Just like the sleeping pills, the application of the sleep apps through smart phone also has no significant improvements on the sleep-wake cycle. Awareness of the metal health complications and association of stress and anxiety with the sleepless has helped in de-medicalization of sleeplessness. In spite of the detrimental effects of the sleeping pills, the doctors suffer from market pressure in prescribing sleeping pills. Thus, proper education and awareness should be provided so that the application of the non-pharmacological interventions occurs towards promoting sleep. Non-pharmacological interventions include healthy diet and mild to moderate physical exercise.

References

Bhat, S., Ferraris, A., Gupta, D., Mozafarian, M., DeBari, V. A., Gushway-Henry, N., & Chokroverty, S. (2015). Is there a clinical role for smartphone sleep apps? Comparison of sleep cycle detection by a smartphone application to polysomnography. Journal of Clinical Sleep Medicine, 11(07), 709-715.

Buffel, V., & Bracke, P. (2018). Medicalization of Sleep Problems in an Aging Population: A Longitudinal Cross-National Study of Medication Use for Sleep Problems in Older European Adults. Journal of aging and health, 30(5), 816-838.

Fleishman, S. (2012). Insomnia: medicalization of sleep may be needed. Nature, 491(7425), 527.

Freeman, D., Waite, F., Startup, H., Myers, E., Lister, R., McInerney, J., & Foster, R. (2015). Efficacy of cognitive behavioural therapy for sleep improvement in patients with persistent delusions and hallucinations (BEST): a prospective, assessor-blind, randomised controlled pilot trial. The Lancet Psychiatry, 2(11), 975-983.

Halfmann, D. (2012). Recognizing medicalization and demedicalization: discourses, practices, and identities. Health:, 16(2), 186-207.

Hislop, J., & Arber, S. (2003). Understanding women’s sleep management: beyond medicalization?healthicization?. Sociology of health & illness, 25(7), 815-837.

Huedo-Medina, T. B., Kirsch, I., Middlemass, J., Klonizakis, M., & Siriwardena, A. N. (2012). Effectiveness of non-benzodiazepine hypnotics in treatment of adult insomnia: meta-analysis of data submitted to the Food and Drug Administration. Bmj, 345, e8343.

Irish, L. A., Kline, C. E., Gunn, H. E., Buysse, D. J., & Hall, M. H. (2015). The role of sleep hygiene in promoting public health: A review of empirical evidence. Sleep medicine reviews, 22, 23-36.

Kompier, M. A., Taris, T. W., & Van Veldhoven, M. (2012). Tossing and turning-insomnia in relation to occupational stress, rumination, fatigue, and well-being. Scandinavian journal of work, environment & health, 238-246.

Kornfield, R., Alexander, G. C., Qato, D. M., Kim, Y., Hirsch, J. D., & Emery, S. L. (2015). Trends in exposure to televised prescription drug advertising, 2003–2011. American journal of preventive medicine, 48(5), 575-579.

Moloney, M. E., Konrad, T. R., & Zimmer, C. R. (2011). The medicalization of sleeplessness: a public health concern. American journal of public health, 101(8), 1429-1433.

Taylor, D. J., Bramoweth, A. D., Grieser, E. A., Tatum, J. I., & Roane, B. M. (2013). Epidemiology of insomnia in college students: relationship with mental health, quality of life, and substance use difficulties. Behavior therapy, 44(3), 339-348.

Van den Bulck, J. (2015). Sleep apps and the quantified self: blessing or curse?. Journal of sleep research, 24(2), 121-123.

Williams, S. J. (2004). Beyond medicalization?healthicization? A rejoinder to Hislop and Arber. Sociology of health & illness, 26(4), 453-459.

Wolever, R. Q., Bobinet, K. J., McCabe, K., Mackenzie, E. R., Fekete, E., Kusnick, C. A., & Baime, M. (2012). Effective and viable mind-body stress reduction in the workplace: a randomized controlled trial. Journal of occupational health psychology, 17(2), 246.