The days following Heath Ledger’s death have swirled with speculation, with tales of hard drugs and prescription pills, of anti-depressants and sleeping tablets. Amid all the mutterings about heroin abuse and cocaine addiction, it is the sleeping pills that seem most startling. Ledger, plagued by the chronic insomnia that often accompanies depression, had apparently come to rely on medication to get him to sleep. “I warned him to stop,” said Jack Nicholson. “I tell people about Ambien [sleeping pill]. Somebody said, ‘Take this, it’s mild.’ I almost drove off a cliff 50 yards from my house.”
Ambien is now America’s leading sleeping tablet. In 2005 alone, 26,5-million Ambien prescriptions were written in the United States. Available only on prescription, it is none the less advertised on television and in magazines. Introduced in 1993 by the medical corporation Sanofi-Aventis, the pill’s active ingredient is Zolpidem, which decreases the time taken to fall asleep and increases the length of time spent sleeping. It is not without controversy: an increasing number of traffic arrests have revealed Ambien to be a factor in impaired driving, prompting a number of lawsuits.
In the United Kingdom, where it is known as Stilnoct, it is suspected in six fatal adverse drug reactions since 2002, according to the Medicines and Healthcare Products Regulatory Agency (MHRA). But these cases have had little effect on sales. Yet Ambien and Stilnoct are just the tip of the iceberg — upon our sleeplessness rests an entire industry.
In 2006 Forbes magazine ran an article about what it termed “the sleep racket”, the $20-billion industry that bloomed around our pursuit of the perfect night’s sleep: money spent on herbal balms, mattresses, sleep clinics and, oh yes, sleeping pills.
Consider this: between 2000 and 2005, the US experienced a 60% increase in sleeping pill use (in the year to September 2005 alone sales of prescription sleeping pills grew by 27%), a fact largely attributable to the aggressive marketing campaigns for drugs such as Lunesta, a prescription sleep aid manufactured by Sepracor Inc. Sepracor’s spending on advertising Lunesta over the drug’s first 11 months was $270-million, exceeding the previous one-year record for advertising of any drug. In 2006, the sleep-aid industry as a whole spent $600-million on advertising — a huge outlay, but not when one considers that sales of Lunesta and Ambien topped $3-billion.
According to the Sleep Council, which represents the bed-and-mattress industry in the UK, two-thirds of people say they get less sleep now than they did a few years ago — about 90 minutes less, according to one leading US sleep expert. “You probably have a generation that is quite sleep disturbed,” says Kathleen McGrath, medical director of the Medical Advisory Service. “I think we are looking at a time bomb.” We buy earplugs, valerian tincture and how-to-sleep books. We put our faith in things named Pillow Pearls and tablets made of passiflora and wild lettuce.
Meanwhile, the science of mattresses grows ever more advanced. The Silentnight Group, the leading bed manufacturer in the UK, sells a bed approximately every 90 seconds, an increasing number of which are made of memory foam — a dense, polyurethane material that adjusts to your body shape and temperature. But we also have pocket spring, open spring, latex, foam and gel, micro-quilted top layers, “which cover the tufting for a soft, bump-free finish”, mattress toppers, pads and protectors. We sleep under duck feathers, goose down and microfibre, and have shiatsu massaging pillows, siliconised cluster fibre quilted pillows and spiral hollow fibre jacquard pillows. Yet we are still driven to seek out advice from our doctors about snoring, sleep apnoea, restless leg syndrome and, most commonly, insomnia.
“Twenty years ago research claimed that we could cut down the eight hours’ sleep to five hours, as three of those hours are spent in ‘light’ sleep,” says Mark Balgrove, senior lecturer in psychology at Swansea University, Wales. “But now we realise that even cutting down by half an hour habitually can cause problems.”
Insomnia affects 5% of the population at any time, and 10% will experience it at some point in their lives. Short-term, or transient, insomnia generally occurs as a result of a change in circumstances — jetlag, say, or a period of stress during examinations or bereavement, and lasts anywhere from a few days to a few weeks.
Long-term insomnia is an inability to obtain adequate sleep that lasts for more than a month, and can continue for years. Symptoms may include having trouble falling asleep, staying asleep or waking up too early in the morning feeling unrefreshed. It leaves sufferers feeling exhausted, irritable and unable to concentrate on simple tasks. Nobody knows what causes it. “Some people are just predisposed to insomnia, much as we talk about people with high or low pain thresholds,” says Kevin Morgan, an insomnia expert at Loughborough University, England.
“By and large, older people are more prone to insomnia than younger people, as are women and people with high levels of anxiety. But it’s important to note that insomnia really means poor daytime performance as a result of no sleep when there is opportunity to sleep.”
Some blame modern sleeplessness on the invention of the electric lightbulb. Others blame our increasingly sedentary lifestyles. “People now are not physically tired but mentally tired,” says McGrath. Or the fact that, unlike in decades past, television and radio stations now run all night.
Our peculiar relationship with sleep is, Morgan suggests, “an extension of our rather strange attitudes to our bodies. We’ve lost touch with our bodies. Living the right kind of life has become the target of the 21st century. Most people know about nutrition and calories and they have cardio-vascular plans, but most people know nothing about sleep.”
Surprisingly, lack of sleep knowledge can also extend to the medical profession. “What many people don’t realise is that doctors aren’t specifically trained to deal with sleep disorders,” says McGrath. “They probably spend less than five hours of training on managing sleep disorders.” The medical solution to sleep problems is arguably over-reliant on medication. “Sleep problems happen over time, so assessing them takes time,” says Morgan. “History-taking is probably the weakest part of diagnosis: it means engaging with a patient — you have to ‘unpack’ the patients.” Few doctors, Morgan suggests, are able to devote the time to history-taking and finding out what lies behind the insomnia.
Most sleeping pills are, like Ambien, prescribed. They work by blocking the formation of memories. “They give you amnesia for the period just before you fall asleep,” explains Balgrove. This works because insomniacs often overestimate how long it has taken them to get to sleep, as well as underestimating how long they have slept. So while a study conducted last year by the American National Institute of Health found that prescribed sleeping pills only grant an extra 12,8 minutes of sleep, patients felt they had actually had an extra 32 minutes of sleep; the amnesiac effect of the pills meant that they had forgotten the period in which they struggled to fall asleep.
The continued attraction is, of course, that they are a very successful treatment for insomnia — in the short term. “They work by shutting off the systems that keep you awake,” Morgan explains. “They make you feel groggy and stupid; they interfere with memory. But tolerance diminishes quickly. After a month they aren’t giving the same hit of sleep, and after three to four months probably not giving any benefit. After a year, it’s probably doing more harm than good.
“The toxicity is very, very low. They won’t poison you. But this isn’t to say they won’t harm you. They are very addictive. They are drugs of dependence and if you take them for long enough you will be dependent — there is evidence in abundance. The paradox is that after taking them for a long time they will not help you sleep. They will cause withdrawal symptoms, and one of the main withdrawal symptoms is insomnia.”
For Morgan, the dominant role of sleeping pills is cause for concern. He would rather see greater access to cognitive behavioural therapy (CBT) for insomnia sufferers. “Five hours of CBT can deliver benefits in more than 70% of cases. It gives a better quality of sleep up to a year later and they have been empowered to look after their own sleep. CBT is about telling people how to think and behave in a way that promotes better sleep.”
“The solution is not another sleeping tablet,” Morgan says. “The biggest problem with contemporary sleeping tablets is that they provide excellent, safe treatment for short-term insomnia. But most insomnia isn’t short-term.”
What we need, he suggests, is to reclaim our sleep. “Sleeping positions are important, mattresses are important, bedroom environments are important. Once you are sold on the idea that elements of your sleep are within your control you can address them. Thirty years of sleeping tablets have created passivity, the idea that it is out of your control. The notion of involving people in their own sleep management is important and effective.” But involving people in their own sleep management first requires a myth to be dispelled — the long-standing idea that we all need eight hours sleep.
“Eight just comes from the national average,” says Balgrove. Though there are some studies that suggest eight hours’ sleep is optimal for health, the crucial factor is that sleep is a personal matter.
“Sleep demand is hard-wired so that most of us know how much we need,” says Morgan. “This personal calibration is far more valuable than the cultural assumption that people need eight hours’ sleep. Eight hours is a piece of mythical nonsense. The average sleep is seven hours, but it’s not meaningful. A new-born baby has on average 17 hours’ sleep. A 10-year-old takes 10 to 12 hours. As we get older, our sleep duration gets shorter. It’s normal, it’s healthy; we have shorter, lighter, more fragmented sleep.”
But it is in many people’s interest for us not to know about the eight-hour myth. It is in many people’s interest for us not to know about CBT as a treatment for insomnia. Because upon our anxieties, our insecurities and our feelings of inadequacy, a multi-billion pound industry is built.
Perhaps sleep is just the latest part of our lives to have fallen prey to big business. The sleep we are shown is airbrushed sleep, and we will never feel satisfied with what we have because we are striving for an ideal slumber that simply does not exist. — Â