Up all night: The medicalization of sleeplessness

Sleeplessness - a universal experience with a variety of causes - may be increasingly diagnosed and treated as the medical condition insomnia, or medicalized. This research provides quantitative and qualitative evidence of the medicalization of insomnia at the level of patient-physician interaction. I analyze 14 years (1993-2006) of data from the National Ambulatory Medical Care Survey, a nationally representative dataset of physician office visits. I describe trends over time for: complaint of sleeplessness, diagnosis of insomnia and prescription of sedative hypnotics (select benzodiazepines, Trazodone and non-benzodiazepine sedative hypnotics [NBSHs]). Independent variables are age, gender, race and insurance status. To measure change over time, I conduct linear regressions using weighted visits, calculate slope estimates and report P-values. I also carry out semi-structured qualitative interviews with patients (N=27) prescribed a sedative hypnotic, and their physicians (N=8). Between 1993 and 2006 complaint of sleeplessness increased 30% (3.3 million to 4.7 million); diagnosis increased 6-fold (869,000 to 5.2 million) and prescriptions for all sedative hypnotics increased. Most notable was the 23-fold increase in NBSHs (550,000 to 12.8 million). Slope change and differences in proportion were positive and significant for insomnia diagnoses, NBSHs and Trazodone. Female gender was significantly associated with prescriptions of Trazodone. Patients 55+ were significantly more likely to receive a prescription for a benzodiazepine or a NBSH. Physicians were cognizant and critical of medicalization. They conceptualized insomnia as a symptom, part of the aging process, or a reaction to stress - not a disease. Despite stated bias, respondents prescribed sleep aids at least some of the time. Compliance was influenced by time constraints, consumerism, and pre-existing prescriptions. Patients entered their office with medical knowledge from non-medical sources including the Internet, social networks and direct to consumer advertising. Patients said that insomnia was a symptom of stress, anxiety or comorbid illness. Fear of addiction to sleep aids was common. Factors mediating their physician interaction were time constraints, pre-existing prescriptions and consumerism. These data elucidate both the increased medicalization of sleeplessness and micro and macro fueling factors. Even when not formally re-defined as insomnia, sleeplessness is increasingly treated with medical solutions

The Medicalization of Sleeplessness: A Public Health Concern

Sleeplessness, a universal condition with diverse causes, may be increasingly diagnosed and treated (or medicalized) as insomnia. We examined the trend in sleeplessness complaints, diagnoses, and prescriptions of sedative hypnotics in physician office visits from 1993 to 2007. Consistent with the medicalization hypothesis, sleeplessness complaints and insomnia diagnoses increased over time and were far outpaced by prescriptions for sedative hypnotics. Insomnia may be a public health concern, but potential overtreatment with marginally effective, expensive medications with nontrivial side effects raises definite population health concerns

Evaluating the Feasibility and Acceptability of Internet-Based Cognitive Behavioral Therapy for Insomnia in Rural Women

Background: Insomnia, one of the most common sleep disorders among women in midlife, is associated with multiple negative health outcomes. Rural Appalachian women are disproportionately affected by insufficient sleep, but their barriers to care (e.g., health care shortages, cultural norms) may prevent intervention. This study assessed the feasibility and acceptability of Sleep Healthy Using the Internet (SHUTi) an Internet-based version of cognitive behavioral therapy for insomnia in Appalachian women ages 45+ years. Materials and Methods: We used mixed methods to assess feasibility (through summaries of recruitment and retention data) and acceptability (quantitatively through online survey scales and qualitatively through interviews). Subject-level responses for satisfaction, adherence, and helpfulness scales were averaged over the multiple response domains and reported as percentages. Interviews were transcribed and coded using a multistage coding process. Results: Forty-six women (average age 55 years) enrolled; 38 completed the SHUTi program (retention = 82.6%). The majority of participants (61%) indicated that SHUTi made things “somewhat better” or “a lot better.” Seventy-six percent reported that they followed the SHUTi protocol “most of the time” or “consistently.” Most participants (84%) ranked SHUTi as “moderately” or “very” helpful. Participants expressed enthusiasm about SHUTi and offered minor suggestions for improvement. Conclusions: This study was the first to asses SHUTi in the health disparity population of Appalachian women. Rich insights gained through quantitative and qualitative data suggest that SHUTi was feasible and acceptable for middle-aged Appalachian women. Given rural Appalachian women\u27s documented barriers to utilizing technology, these results hold promise for SHUTi\u27s utility in other rural populations. Future research should incorporate a randomized case–control design within a larger sample and consider participants\u27 suggestions for improvement

The Incomplete Medicalization of Obesity: Physician Office Visits, Diagnoses, and Treatments, 1996-2014

OBJECTIVES: Despite increased awareness of obesity-related health risks and myriad treatment options, obesity still affects more than one-third of persons in the United States and is a substantial public health problem. Studies show that physicians play a key role in obesity prevention and treatment. The objective of this study was to examine the extent to which obesity is diagnosed and treated at the level of patient-physician interaction. METHODS: We used data from the National Ambulatory Medical Care Survey (NAMCS), a nationally representative data set of US physician office visits. We estimated the number of obesity diagnoses and prescriptions of weight-loss management solutions (exercise counseling, diet counseling, or weight-loss drugs) in clinical practice from 1996 through 2014. We also calculated rates of obesity diagnosis and compared these rates with national rates of obesity based on body mass index data from the Behavioral Risk Factor Surveillance System (BRFSS) for the same period. RESULTS: The estimated number of weight gain-related physician office visits increased from 2.3 million in 1996 to a peak of 7.6 million in 2012, and then fell to 4.5 million in 2014. National estimates of obesity diagnoses resulting from physician office visits ranged from 7.1 million in 1996 to 12.7 million in 2014 and substantially outnumbered the estimates for weight gain-related physician office visits throughout the study period. Estimates of exercise counseling and diet counseling and weight-loss medication prescriptions resulting from physician office visits fluctuated over time but never exceeded obesity diagnoses. When compared with national rates of obesity from the BRFSS, rates of obesity diagnoses resulting from physician office visits were substantially lower in the NAMCS (17%-30% vs 1%). National trends for weight-loss medication prescriptions closely mirrored those of weight gain-related physician office visits, even though fluctuations were substantial. CONCLUSIONS: Our results suggest that obesity is largely underdiagnosed and undertreated in clinical encounters. Future studies should investigate the structural changes needed to better engage physicians in obesity prevention and care. Practitioners should also reflect on their biases in treating obesity as a chronic disease

The Medicalization of Sleeplessness: Results of U.S. Office Visit Outcomes, 2008–2015

Previous analysis of U.S. physician office visits (1993–2007) indicated that the medicalization of sleeplessness was on the rise and had potentially negative implications for population health. Our study asks if the medicalization of sleeplessness at the level of patient-physician interaction has persisted over time. Using the most recent years available (2008–2015) of the National Ambulatory Medical Care Survey we calculated nationally representative estimates for four sleeplessness-related outcomes of physician office visits: sleeplessness complaint, insomnia diagnosis, and prescription of benzodiazepine and non-benzodiazepine sedative-hypnotics (NBSH). To test for the significance of the linear trajectory, we ran a series of bivariate linear models. We tested three hypotheses grounded in the medicalization framework: if the medicalization of sleeplessness at the interactional level is continuing at a rate comparable to previous analyses, sleeplessness-related outcomes will continue to increase significantly over time (Hypothesis 1); NBSH prescriptions and insomnia diagnoses will continue to outpace sleeplessness complaints (Hypothesis 2); and insomnia diagnoses and use of sedative-hypnotics will increase or remain concentrated among age groups who lack the changing sleep patterns and commonly occurring comorbidities associated with older age (Hypothesis 3). Support for these hypotheses was mixed. Unlike previous analyses wherein all sleeplessness-related outcome trends were positive and statistically significant over time, regression analyses revealed a significant negative NBSH prescription trend 2008–2015 (slope, b = −699,628, P \u3c 0.05). No other associations were significant. Younger age groups were most likely to receive an insomnia diagnosis and NBSH prescription. These trends imply that the medicalization of sleeplessness at the level of patient-physician interaction may be on the decline. We suggest that increasingly negative portrayals of sedative-hypnotics, conservative practice recommendations, and decreased direct-to-consumer advertising for NBSH may decrease consumerism and physician compliance related to the medicalization of sleeplessness. We conclude with a discussion on non-pharmaceutical methods of reducing sleeplessness relevant to population health