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From Wall Street to Neverland: The Year America Didn't Sleep

The public health burden of insomnia on the US is measured in the hundreds of billions of dollars. While we routinely cut calories, or cram in exercise, sleep has not even entered the conversational lexicon.
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America didn’t just lose money in the Crash -- America lost a lot of sleep. The annual Sleep in America Poll published by the National Sleep Foundation focused on Health and Safety this year. The report is available on line for anyone to download. It makes for compelling reading.

From Wall Street to Neverland, Americans have been sleepless. The starkest example of the struggle with insomnia came earlier this year on June 25th, when Michael Jackson’s quest for sleep resulted in death. In these columns we have discussed some of the painful lessons derived of those Propofol Lullabies. A year or so earlier, in an anonymous New York City night, we had quietly lost the incandescent talent of Heath Ledger who had also struggled with insomnia in the weeks leading up to his death. This had followed Britney Spears' very public insomnia, preceding her hospitalization for mental illness. The lives of these celebrities is far, far removed from those of my patients, but the struggle for rest and sleep is a universal experience. And money simply can’t buy it.

One in three Americans is experiencing a sleep disorder due to economic concerns. Astonishingly, these findings have been little discussed in the professional academe or in the public sphere. This past week at the annual congress of the American College of Chest Physicians, in San Diego I discovered my colleagues were not always aware of such dramatic observations.

Since I first read the survey this spring, I began adding a single question to my interviews when I meet new patients for the first time: “ Without intruding into your financial affairs, do you believe the economy has affected your sleep?” The response has been startling. Every sector of the population relates to this question, whether the patient is a 42 year old account manager for a hedge fund describing a flare of insomnia as Lehman Brothers began its plummet over the edge, or an 87 year old grandfather concerned about his grandchildren’s future, or an overworked physician struggling to make college fees, or a single mom working in a pet store late into the night, or a 60 year old ex-service man taking on an extra shift at UPS for health insurance benefits or even a loan book manager for an international investment bank. There has been almost no patient I have interviewed who cannot relate to this observation, yet the discussion is barely beginning.

Americans are extremely concerned about the economy. They list economic fears, including the economy in general, more specific fears relating to job security and health coverage, ahead, way ahead, of concerns about the war in Iraq, the war in Afghanistan or the interminable global war on terror. Americans are anguished and hurting and its affecting their sleep.

Speaking to a physician colleague recently about this survey I was met with irritated resignation. Well, what can we do about this? We can begin by acknowledging the realities that many more individuals are experiencing insomnia in the slow motion collision that has been our economy of recent. Empathizing about this problem as a shared, national experience can be helpful and patients often sense that they are finally being heard in a climate where economic decisions are being made by faceless suits remote from reality. To quote my mentor from residency, Dr. Michael Ammazzalorso, "as physicians we are privileged to be closer to our patients than a priest is to his parishioner". These are times when we need to remember to minister to ourselves and each other. Sharing a nation’s loss and beginning to examine its many manifestations by spending time hearing about them from our patients can accomplish much.

In the endless 24/7 news cycles since the 2008 implosion of the Dow from the vertiginous altitudes of 14,000, the impact of the economy on sleep, or the impact of sleeplessness on the economy, has been a silent void. We live in a culture of not-so-wholesome Sleep Machismo and economic hardship is bringing the extremes of American lifestyles into sharp relief. Patients who are parents are contorting their schedules to accommodate work hours, long commute times, shift work, child responsibilities, homework and even higher learning. Patients who are unemployed are struggling fiscally, emotionally and without the structure of work, which has become a form of puritanical Americanism. As a nation we are known for our long work week, few vacation days and endless work hours. In contrast, the unemployed have lost their church of redemption -- workaholism, which has been, for a long time the foundation of a uniquely American ethos. Possibly only the Japanese rival us in this pursuit. Outside of a workplace, Americans often find themselves deprived of purpose, community, means and hope. The speed at which health coverage is lost following the end of a job adds to calamity and many patients attend for consultation under pressure of a rapidly uncoiling COBRA coverage.

In times like these, it is, as my colleagues have pointed out, hard to offer constructive help. In a health care system where patient encounters result in investigations and financial burden, we have to remember how to dispense practical advice. We must target behaviors in a way that results in meaningful change for our patients without submitting to the model of medicine as a diagnostic temple serving evaluation yet eternally devoid of healing. We must help and heal, even without a DRG code check box.

We begin by educating our patients about how we sleep, why we need sleep and how to sleep better. Many times a detailed interview can uncover obvious behavior to target. As a nation we are growing up without learning how to fall asleep or how to build an environment which promotes sleep at bedtime. Enter economic calamity and transient, acute insomnia quickly becomes chronic and untreated insomnia contributes to depression. Daytime performances decline, memory is impaired, attention wavers. Tempers fray, workplace litigation costs rise, health care utilization goes up. Workplace conflicts proliferate. I could go on.

The public health burden of insomnia on the United States is measured in the hundreds of billlons of dollars. While some of the costs are direct, many are indirect: covering for staff shortages due to absence, accidents triggered by sleeplessness and the impact of sleeplessness on wider society. Much of this decline is unaddressed in employee wellness programs, or in regular visits to the clinician. While as a nation we routinely cut calories, or cram exercise into demanding schedules, sleep has not even entered the conversational lexicon.

At a time of extraordinary hardship, we can ease suffering by shining the spotlight on America’s sleep habits. We need to look at our culture of Sleep Machismo which views sleep need as an expendable luxury rather than a biological necessity and the brilliant lessons extracted from Dr. Mathias Basner’s evaluation of the federally administered American Time Use Survey and his work at the Philadelphia School of Medicine. I will be devoting a specific column to his fascinating work. We need to acknowledge the socioeconomic impact of a sleepless, overworked nation in a climate of economic volatility and ignite a dialogue on protecting our most vital function of wellness: sound sleep in unsound times.

Without doubt, this is a conversation long overdue. From Wall Street to Neverland, it is time we realized: unlike Greed, Sleep is indeed Good. Americans are not only in financial debt but also rapidly spiraling sleep debt. Losing sleep is costing us money and losing money is costing us sleep.

Its time to stem the losses.