‘Sometimes, it's easier to write the prescription’: physician and patient accounts of the reluctant medicalisation of sleeplessness

Abstract

The medicalisation of sleep is a rich and growing area of sociological interest. Previous research suggests that medicalisation is occurring within the context of physician office visits, but the inner workings remain unclear. This study is the first to provide perspectives on the office visit interaction from both sleepless patients (n = 27) and the physicians (n = 8) who treat them. Analyses of semi-structured qualitative interviews reveal that sleep-related conversations are typically patient-initiated in routine office visits. Physicians and patients conceptualised insomnia as a symptom of another issue (depression), an everyday problem of living (stress) or the result of a natural life process (aging). Lack of sleep was not necessarily linked to daytime impairment. Even though sleep aids were routinely requested and prescribed, patients and physicians consistently expressed attitudes of reluctance toward the use of sedative hypnotics. I call this a case of 'reluctant medicalisation' and highlight the liminal space between pathology and normalcy inhabited by patients and physicians. I also build on recent work acknowledging the dynamics between macro and micro levels of medicalisation and illustrate the influence of multilevel 'engines' (consumerism, biotechnology, managed care and physicians) in patients' and physicians' accounts. A virtual abstract of this paper can be viewed at: https://youtu.be/7uLHOJPHF0I.

Selling slumber: American neoliberalism and the medicalization of sleeplessness

“…Particularly, innovations in biomedicine have transformed health culture to one that is critically concerned with prevention of illness and risk assessment (Clarke et al, ). Waggoner (, p. 66) explains, “Modern medicine and public health can be understood as grand attempts to tame the future, to contain risk, to exert control where control is not fully possible.” As such, people are increasingly seeking out new ways to maximize their personal health (e.g., Potter et al, ), and despite some patient resistance (see Williams, Gabe, & Martin, ) or physician reluctance (see Moloney, ), they overwhelmingly accept and rationalize pharmaceutical drugs as a viable solution to medicalized conditions (e.g., Gabe, Coveney, & Williams, ; Moloney, Konrad, & Zimmer, ). Indeed, pharmaceutical companies capitalize on this “healthicization” of society by marketing self‐diagnosis to patient‐consumers (Ebeling, ).…”

“…In an environment where physicians feel ethically obligated to reduce human suffering whether medical or nonmedical in origin, proffering prescriptions may, at times, seem their best or only course of action (Conrad, ). Compounding these dynamics are time constraints (Konrad et al, ), increased demands from patient‐consumers, and physicians' lack of training in their patients' social needs (Moloney, ). Further, physician decisions have been heavily influenced by education and incentives provided by Big Pharma representatives (Dumit, ; Wosinska, ).…”

“…Though interaction dynamics, time, and outcomes may vary by age, race/ethnicity, gender, and other factors (Peck, ; Peck & Denney, ), U.S. outpatient visits average 10 min of face‐to‐face time and physicians are expected to “prioritize, personalize, and integrate care for an average of 3 to 4 problems” (Stange, , p. 2). Physicians may be motivated to produce a sleep aid prescription so they can move more quickly to the next patient (Moloney, ). Physicians also face pressures from patients who are influenced by direct‐to‐consumer‐advertising (DTCA).…”

“…Physicians also face pressures from patients who are influenced by direct‐to‐consumer‐advertising (DTCA). DTCA may place patients and physicians in oppositional roles, with physicians forced to contradict patients' “knowledge” gained through DTCA (Moloney, , p. 342). Ultimately, DTCA seems to significantly impact both patient requests for specific medication and physician prescribing patterns (Gilbody et al, ).…”

“…Moloney's () qualitative study of patient and physician accounts of sleeplessness‐related office visit interactions found evidence both for the medicalization of sleeplessness (i.e., common if uncomfortable life issues such as stress and anxiety are treated with medical solutions) and for Conrad's hypothesis that physicians are incentivized to offer prescriptions for patients' suffering. One physician, who claimed he “never” prescribed sleep aids, noted

The caveat here is that I just saw a woman yesterday, actually, who is a 78‐year‐old woman; very nice older lady with diabetes, and her daughter‐in‐law is dying of ovarian cancer.

…”