Beyond the Medicalization of Insomnia

Audrey Wagner
10
1863

Recent statistics indicate that 90% of people who suffer from depression also suffer from insomnia and that more than half of Americans lose sleep from stress or anxiety. Therefore, rethinking psychiatric care might include examining how our Western healthcare system treats insomnia. In this article, I will share such an examination. Then I will share research that suggests how we might move beyond the medicalization of insomnia. For the purpose of simplicity, I will use the word “insomniacs” to refer to those who experience insomnia as difficulty falling or staying asleep or poor quality sleep that results in some level of daytime impairment, the definition given by the American Academy of Sleep Medicine.1

My examination of how our healthcare system treats insomnia first entails a personal experience that began over ten years ago and lasted two years. When job-related stress led to severe insomnia, I was prescribed a large dose of Klonopin over many months. I endured a confusing and horrific battle with Klonopin dependence and withdrawal, during which time the doctors I visited offered no insight, validation, or help. I was advised by a family doctor to stop taking Klonopin abruptly, which I later learned is dangerous and even life-threatening. I was told by another doctor that benzodiazepine withdrawal symptoms didn’t exist, even while I was in the throes of withdrawal insomnia. Each doctor I saw prescribed me sleeping pills, but none mentioned their risks. Ultimately, I had to leave our healthcare system behind in order to persevere through the withdrawal insomnia and regain natural sleep.

When I recovered from Klonopin withdrawal, I wanted a lot of distance from the traumatic experience. Yet, after a few years of sleeping well naturally, I was ready to look back in time in order to tell my story through my book and through an article here at Mad in America published in 2014.

Yet my personal story is only the beginning of my examination of how our healthcare system treats insomnia. The remainder of my examination does not come from stories but rather from evidence that sleeping pills are harmful. Years after publishing my personal story, I embarked on the journey of searching for such evidence. After all, if I could show that warnings about sleeping pills are based on more than stories (anecdotal evidence), I might help others avoid the nightmare I went through.

My research indeed revealed the sad yet unsurprising conclusion that sleeping pills are unsafe for insomniacs. I have more certainty than ever that my story of tranquilizer dependence and withdrawal is by no means unique.

I will share what I found. To begin with, insomnia is viewed in our healthcare system not as a disease or illness but rather as a symptom or condition.2 Mayo Clinic calls it a disorder that typically results from “stress, life events or habits that disrupt sleep.” Likewise, sleep doctor Tom Scammell confirms that most insomniacs “don’t have anything wrong with their sleep-promoting mechanisms.” In other words, insomnia does not mean there is something inherently wrong with one’s ability to sleep.

Yet our healthcare system is “medicalizing” insomnia, according to Dr. Abigail Zuger.3 The medicalization of insomnia is something we find in drug advertisements and conventional medical advice online. For example, articles from the National Sleep Foundation and Mayo Clinic advise insomniacs to call their doctors. Yet when insomniacs end up in doctors’ offices, they are often prescribed sleeping pills. The American Academy of Sleep Medicine admitted, in their 2017 Clinical Practice Guideline, that sleeping pills are “by far, the most common approach to therapy” for insomnia.4

Therefore, it is important to find out what the evidence reveals about these drugs.

In their 2017 Clinical Practice Guideline, the American Academy of Sleep Medicine presented the results of an assessment of clinical trials on commonly prescribed sleeping pills of various classes. They found that the clinical trials provided low-quality evidence for sleeping pills’ effectiveness and safety. They also admitted that any benefits gained from sleeping pills tend to disappear as soon as the pills are discontinued. They concluded that “many commonly used drugs, including some which carry FDA approval for treatment of insomnia, are not recommended.” We learn from a professional society devoted to the subject of sleep that sleeping pills cannot necessarily be recommended based on the evidence.

Furthermore, Dr. Daniel Kripke has published a review of sleeping pills’ adverse effects, using a large collection of data. He found that sleeping pills are causally related to excess mortality, infections, increased cancer, clinical depression, accidents, withdrawal insomnia, and other withdrawal symptoms including anxiety, panic, and epilepsy.5 In yet another review of studies, Dr. Kripke found that clinical trials have demonstrated that sleeping pills cause insomnia! He reviewed trials involving three different classes of sleeping pills and found that the insomnia of those in the control groups was worse at one, four, and eight weeks after discontinuing sleeping pills than was the insomnia of those in the placebo groups.6

Steering folks away from sleeping pills can be challenging when they are encouraged though drug advertisements, conventional medical advice online, and doctor’s visits to take them. Yet there is hope that the truth about sleeping pills will become more commonplace. As it does, however, we are faced with an even greater challenge: to move beyond the medicalization of insomnia in order to help people sleep better naturally.

Although some doctors offer excellent sleep tips and cognitive behavioral therapy for insomnia, many insomniacs may not be sufficiently helped by these. According to a Sleep Disorders Medicine journal, cognitive behavioral therapy does not produce “optimal therapeutic outcome.”7 I did not find evidence in my research that our healthcare system, including even the American Academy of Sleep Medicine, is aware of a treatment option that is both safe and effective for the issue of insomnia. Therefore, insomnia sufferers and those who care for them might need to search for help within an alternative paradigm.

Anyone broaching the subject of how to sleep naturally is likely overwhelmed, as I was, in the face of all the information in the field of health. Our industrial lifestyles, the Western diet, our modern healthcare system, and the field of nutrition are relatively recent in history. Therefore, we are in the midst of discovering that how we live, eat, and manage our health in modern Western society can be detrimental to us and, dare I say, to our ability to sleep. Statistics indicate that people sleep 20% less today than they did 100 years ago. Therefore, we might want to probe deeply into how our lifestyles are affecting our sleep.

While sifting through an intimidating sea of information, I read some research articles about insomnia, nutrition, and health and noticed some connections between them. Drawing from that information, I’d like to suggest a paradigm that could help us move beyond the medicalization of insomnia. This paradigm is not unique to me, but it may be challenging to advocate within the context of conventional medical advice.

In order to arrive at this paradigm, let’s first look at what some research says about the causes of insomnia.

Authors of a Sleep Medicine Clinics journal demonstrate through many objective measures that insomniacs tend to be in a state of hyperarousal around the clock and have higher levels of the stress hormone cortisol.8 In addition, the authors cited studies showing that stress and stressful circumstances comprised many of the factors linked with insomnia. You might think that where I’m going with this is the need to reduce stress in our lives. Although we certainly want to work toward less stress and better mental health, that wasn’t my ultimate conclusion—there was more to the story. Research articles link insomnia not only with stress but with inflammation,9 aging,10 and caffeine intake.11 What fascinates me about these links is that stress, inflammation, aging, and caffeine are all correlated with fewer nutrients! Sources affirm that stress depletes nutrients,12 that inflammation is linked to the nutrient-deprived and inflammatory Western diet,13 that aging causes us to absorb fewer nutrients, and that caffeine inhibits nutrient absorption.14

This takes us to the paradigm I’d like to suggest, which is that insufficient nutrients is a common cause of insomnia in modern times. Furthermore, that insomniacs have lower levels of nutrients is itself supported by clinical evidence.15 Therefore, I believe a nutrient-dense diet is a primary cure for insomnia, along with practicing good sleep habits.

I did not originally arrive at this conclusion through research. Rather, I personally experienced the power of nutrients to give me a good night’s sleep when I recovered from Klonopin withdrawal. I was drinking green smoothies and taking a liquid multivitamin when my natural sleep returned. I began sleeping better than before I’d ever had any sleep problems whatsoever. In the years since, through trial, error, and research, I have pinpointed basic nutritional actions that I must take to sleep well—actions that, to varying degrees, are supported by research and that also reflect the paradigm I’m suggesting.

In a health care system that medicalizes insomnia and prescribes sleeping pills, it may seem unbelievable that nutrition could greatly help or even eliminate our sleep problems. I understand. In the days when I was dependent on Klonopin, I had never once heard the idea that food and its nutrients had anything to do with sleep. Yet the premise that a nutrient-dense diet is a primary cure for insomnia is supported in research directly; it is also supported indirectly in that insomnia is linked to factors that create nutrient deprivation. Furthermore, this premise makes sense of the connection between a modern lifestyle of fewer nutrients and the fact that we sleep 20% less than we did 100 years ago.

My additional research as well as my nutritional recommendations can be found here. Yet for our present purpose, I have drawn from some of my research to examine how our healthcare system treats insomnia and to offer an explanation for how we might move beyond its medicalization. The alternative paradigm I suggest is that nutrition is a primary cure for insomnia. I hope this paradigm will be seriously considered and tried. I hope for it to become part of the overarching effort to rethink psychiatric care. Although such a paradigm challenges conventional medical advice for insomnia, I hope for others to contribute to it with further research and, most of all, personal experience of the power of nutrition to help us sleep.

Show 15 footnotes

  1. Jules Sowder, “Insomnia Statistics,” The Better Sleep Guide, accessed January 19, 2018, https://www.better-sleep-better-life.com/insomnia-statistics.html.
  2. S. Schutte-Rodin et al., “Clinical Guideline for the Evaluation and Management of Chronic Insomnia in Adults,” Journal of Clinical Sleep Medicine 4, no. 5, (October 2008): 487-504, https://www.ncbi.nlm.nih.gov/pubmed/18853708.
  3. Abigail Zuger, “Is Insomnia A Disease?” Medscape, accessed April 03, 2017, https://www.medscape.com/viewarticle/749277_1.
  4.  Michael J. Sateia et al., “Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults: An American Academy of Sleep Medicine Clinical Practice Guideline,” Journal of Clinical Sleep Medicine 13, no. 2 (February 2017): 307-49, http://doi.org/10.5664/jcsm.6470.
  5.  Daniel F. Kripke, “Hypnotic Drug Risks of Mortality, Infection, Depression, and Cancer: But Lack of Benefit,” F1000Research 5, no. 918 (May 2016), http://doi.org/10.12688/f1000research.8729.1.
  6.  Daniel F. Kripke, “Hypnotics Cause Insomnia: Evidence from Clinical Trials,” Sleep Medicine 15, no. 9 (September 2014): 1168-69, http://doi.org/10.1016/j.sleep.2014.08.001.
  7.  Charles M. Morin and Ruth M. Benca, “Nature, Evaluation, and Treatment of Insomnia,” Sleep Disorders Medicine (May 2017): 673-696, http://doi.org/10.1007/978-1-4939-6578-6_37.
  8.  Maria Basta et al., “Chronic Insomnia and the Stress System,” Sleep Medicine Clinics 2, no. 2 (June 2007): 279-91, http://doi.org/10.1016/j.jsmc.2007.04.002.
  9. Hyong Jin Cho et al., “Sleep Disturbance and Longitudinal Risk of Inflammation: Moderating Influences of Social Integration and Social Isolation in the Coronary Artery Risk Development in Young Adults (CARDIA) Study,” Brain, Behavior, and Immunity 46 (May 2015): 319-26. http://doi.org/10.1016/j.bbi.2015.02.023.
  10.  Institute of Medicine (US) Food Forum, “Nutrition Concerns for Aging Populations,” in Providing Healthy and Safe Foods As We Age: Workshop Summary, (January 2010), https://www.ncbi.nlm.nih.gov/books/NBK51837/.
  11.  Ian Clark and Hans Peter Landolt, “Coffee, Caffeine, and Sleep: A Systematic Review of Epidemiological Studies and Randomized Controlled Trials,” Sleep Medicine Reviews 31 (February 2017): 70-78, http://doi.org/10.1016/j.smrv.2016.01.006.
  12.  Vicki B. Griffin, Edwin Neblett, and Evelyn Kissinger, “Stress Effects on Nutrition,” Lifestyle Laboratory, accessed December 5, 2017, http://lifestylelaboratory.com/articles/stress-effects-nutrition.html.
  13.  Dallas Hartwig and Melissa Hartwig, It Starts with Food (Las Vegas: Victory Belt Publishing, 2014), 76.
  14.  Sam Robbins, “Top 10 Caffeine Related Health Problems,” HFL Solutions, accessed April 25, 2017, https://www.hflsolutions.com/ne/free_articles/CaffeineProblems_To p10.pdf.
  15.  Sara Sarrafi Zadeh and Khyrunnisa Begum, “Comparison of Nutrient Intake by Sleep Status in Selected Adults in Mysore, India,” Nutrition Research and Practice 5, no. 3 (June 2011): 230-35, http://doi.org/10.4162/nrp.2011.5.3.230.

10 COMMENTS

  1. Objectively, to solve an insomnia, it is necessary to stop working. We must sleep when we are sleepy, even when socially or economically it is not the moment. After having solved the sleep deficit, you have to wait to gradually recalibrate. It takes a while.

    The problem of insomnia is rather a social problem, at different levels. How can society tolerate you being tired “at the wrong time”? Do you need to sleep “at the wrong time”? This is where sleeping pills come in.

    It does not matter that sleeping pills exacerbate insomnia in the long run, and causes all sorts of problems: sleeping pills, like all psychiatric products, are disciplinary instruments. Employers can not allow their employees to leave their job for insomnia – which, objectively, would be the best thing to do – as it would be too much for absenteeism.

    Absenteeism at work is one of the essential factors of bad medicine.

    • The industrial revolution has created much of the insomnia that we have now. Historically, people sleep in increments: going to bed, waking in the middle of the night to stoke the fire and check on livestock, then back to sleep for a few hours, work, nap, etc. It is the regimenting of sleep that is the issue.

      • I had the same thought. Industrialization forces us all to comply with many arbitrary schedules and rules, often starting as infants. This is highly stressful and screws not only with our sleep schedules but any other part of our circadian rhythms. Not to mention disruptions in nutrition, toxic chemicals in the environment, noise and light pollution, and on and on. Psychiatry is the handmaiden of industry, helping blame individuals for the costs of industrialization.

        • Yes! And I have always felt a need for more sleep in the winter, less in the summer. And pre-industrialization, summer was when the work at hand required he most energy: out in the sunshine, harvesting, building, canning, tasks that were pretty draining. But in the winter, the tasks were more like quilting and sewing, and weaving blankets or rugs.

  2. This is becoming a political issue because health insurance wants to dictate the medical industry. There is so much momentum now to blame everything for “dementia” and Alzheimer’s” because the insurance and health industry doesn’t want to continue to lose money. Yet there isn’t scrap of solid evidence which points to any element as a causative factor in this debate.
    I find it rather amazing that hyper arousal was listed as a cause yet the author does nothing to address the causes of hyper arousal (CPTSD, current domestic/environmental violence, etc). These are issues that will not be resolved by “improving nutrition”. I am bored with people who are living in secure, stable environments preaching to the rest about how we should just do what they did. How about we have the right to do what works for us, in our situation? Medication may not be the best choice, but there are people who could not function and be productive without it.
    This is another great example of the “medical community” handing out addictive chemicals and having to answer to no one when it backfires and ruins people lives. Just lends more credence to the idea the “health care” is simply an “illness maintenance system”. What will they do when the masses pay them no concern anymore?

  3. In 2001, historian Roger Ekirch of Virginia Tech published a seminal paper, drawn from 16 years of research, revealing a wealth of historical evidence that humans used to sleep in two distinct chunks.

    His book At Day’s Close: Night in Times Past, published four years later, unearths more than 500 references to a segmented sleeping pattern – in diaries, court records, medical books and literature, from Homer’s Odyssey to an anthropological account of modern tribes in Nigeria
    Read more http://www.bbc.com/news/magazine-16964783

  4. Another one exploiting people who have been destroyed by benzodiazepines. A lot of these people will actually have Akathisia and this is what makes benzo withdrawal very serious, and why I abhor such exploitation. First of all, study Heather Aston on YouTube. The important thing to know is not really about cortisol, it’s about glutamate. Glutamate is running around out of control. That’s what benzos do because the body HAS to change itself in response to benzodiazepines potentiating GABA . No matter how slowly you come off benzos, you end up with this problem. Click on my name to study the importance of magnesium and B6 (active form PLP). Too busy at the moment to go through it again. Magnesium 100mg has to be taken in the form of a capsule, cut in half, pour powder onto tongue to dissolve, (same with B6 PLP) then you will not have any rear end problems, which stops people from using Mg long term. Sorry but there is no easy way out, it goes on for a long time. That is the important stuff.

    http://benzo.org.uk/BNF.htm

    Use a pill crusher from Amazon or where every else plus do this:

    https://www.youtube.com/watch?v=EGNb5LetgDw

  5. My worst insomnia bout ever was iatrogenic. At 20 I went on Anafranil and couldn’t sleep for 3 weeks.

    I asked Dr. M. if Anafranil could cause that–I had been sleeping okay till the night after starting it. He swore up and down it never had that effect on anyone and I had better keep taking it. I began to hallucinate and had severe mood swings, imagined things that weren’t happening, and stopped eating.

    Things got even worse. 10 mg of Haldol turned me into a zombie and I had at least 1 seizure a day the 2 years I took it. My new psychiatrist said maybe my Haldol dose was too high (but he never reduced it somehow.) I asked him to look up the side effects of Anafranil. One of his assistants got out a big directory of pills. Sure enough, insomnia, mood swings, hallucinations, delusions, loss of appetite…all were listed.