Sleep science: Broken dreams

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Meredith Wadman lifts the blanket on the creeping medicalization of sleep in the United States.

The Slumbering Masses: Sleep, Medicine and Modern American Life

Univ. Minnesota Press: 2012. 312 pp. $24.95, £18.50 9780816674749 | ISBN: 978-0-8166-7474-9
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Millions of people in the United States struggle to achieve that great American dream, a 'good night's sleep'. So says Matthew Wolf-Meyer in his ambitious The Slumbering Masses. He contends that capitalist necessity defines sleep in the country today, shoehorning sleepers into a societally convenient but physiologically arbitrary eight-hour night.

Those who can't manage the prescribed amount of slumber at the prescribed time are often labelled disordered sleepers. Wolf-Meyer's message is that society should bend to accommodate, even celebrate, diversity in sleeping behaviour, rather than branding nonconformism pathological.

For now, night owls and others who fail to adapt to the eight-hour, nocturnal norm — whether owing to disease or a particular hard-wired biology — are a boon to the pharmaceutical industry. Wolf-Meyer, an anthropologist, calls for a shift towards more flexible organization of workdays, school and social lives, and away from the assumption of monolithic “slumbering masses”. Otherwise, he warns, “Americans may be doomed to a future of proliferating sleep disorders, amphetamine breakfasts, and sedatives for dinner.”

Some people need more rest than the prescribed eight hours a night — or need it at different times. Credit: H. KORVOLA/GETTY

Wolf-Meyer lays much responsibility for the medicalization of sleep at the feet of a US sleep-medicine establishment that has grown up since the 1950s. Its roots, however, emerge in his fascinating history of the Protestant origins of sleep in the United States. The influential Puritan minister Cotton Mather argued in the late seventeenth century that those with a proclivity for the luxuries of slumber were failing in their earthly and God-given duty to be productive. The bed, Mather opined, is one of just a few places where “the Devil has laid out most fatal snares”. A generation later, Benjamin Franklin turned the same message positive with his still-famous dictum, “Early to bed, early to rise, makes a man healthy, wealthy and wise.”

This morality handily converged with the twentieth-century idea of 'normal sleep': a consolidated nocturnal experience programmed by biology, but potentially moulded by behaviour modification and, of course, drugs. The work of sleep-science pioneer Nathaniel Kleitman, who in 1938 descended into Mammoth Cave in Kentucky to try to realign his biology to a 28-hour day, thrust an awareness of sleep research into the public eye. It also reinforced the idea that sleep can be controlled by willpower — a concept further cemented by Kleitman's student, William Dement.

Dement founded the first sleep laboratory, at Stanford University in California, in the early 1970s. He understood healthy sleep “as resting upon a biological foundation of eight quiet, motionless and consolidated hours of sleep ... between sunset and sunrise”, writes Wolf-Meyer, arguing that Dement's The Promise of Sleep (co-written by Christopher Vaughan; Delacorte, 1999) “promotes a model of nature and human biology from which all variations are disorders”. Work such as Dement's has, in Wolf-Meyer's view, been one factor in helping to pave the way for the modern pharmaceutical industry to find a broad new market among disordered US sleepers. Many of these sleepers are given the catch-all diagnosis of 'excessive daytime sleepiness', the use of which in the medical literature has exploded in the past ten years.

Those looking for an exhaustive pharmacopeia of the sleep-medicine industry will not find it here. Wolf-Meyer notes that US drug-maker Sepracor spent “hundreds of millions of dollars” on the US launch of the sedative Lunesta (eszopiclone). But he offers only one example to support his contention that companies are widening their net: pharmaceutical firm Cephalon's successful effort to expand the user base for the stimulant Provigil (modafinil) from people with narcolepsy to those with sleep apnoea and 'shift-work sleep disorder'. Neither has Wolf-Meyer tracked down the associated and — he implies — growing revenue numbers for leading stimulants and sedatives. Such figures would buttress his claim that in “a few short years, excessive sleepiness may successfully become the new erectile dysfunction”.

Wolf-Meyer might have delved deeper if his scope had been narrower. As it is, he covers everything from the socialization of children to sleep at the appropriate hour (think of Margaret Wise Brown's bedtime classic Goodnight, Moon) to the use and abuse of caffeine and other stimulants, and the plight of workers in Indian call centres, forced to synchronize their hours with US time. Yet in other ways, the broad treatment pays dividends. It is illuminating, for instance, when Wolf-Meyer takes us inside a Minnesota sleep clinic where medics are struggling to help a sleepless young girl already prescribed five drugs.

Implicit in Wolf-Meyer's analysis is that the medicalization of sleep is a profit-driven pursuit. No doubt economics did indeed have a big role in the rise of sleep medicine, but the author finds little room for the real benefits of some treatments. Can it be bad when medication prevents a narcoleptic from falling asleep at the wheel? And I, as a sleep apnoeic with daily work and family responsibilities, am indebted to the machine that keeps my airway open at night and prevents what would otherwise be literally hundreds of sub-conscious wakenings.

The Slumbering Masses suffers in many places from jargon. Sentences such as, “Normative desire facilitates the functioning of everyday spatiotemporal hegemony and is in turn formed through that very same hegemony” made me long for a lay-friendly translation.

But there are passages of telling clarity. Wolf-Meyer tells the story of Betsy, a woman in her 50s who fought insomnia for decades. She tried, she confesses, “lots and lots of drugs. Everything from benzo[diazepines] to Xanax, antidepressants, and all the tricyclics [as well as] muscle relaxers mixed with other drugs. And they're effective for a while, and then they all wear off.”

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Wadman, M. Sleep science: Broken dreams. Nature 490, 173–174 (2012) doi:10.1038/490173a

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