Prescriptions and proscriptions: moralising sleep medicines

Exploration of effects of galvanic vestibular stimulation on circadian rhythms and its associations with sleep and spatial memory in patients with breast cancer: The ICANSLEEP-2 protocol

BACKGROUND

Patients with breast cancer (BC) exhibit circadian rhythm disruptions, mainly of rest-activity rhythm (RAR), of which sleep is an essential component, and cortisol rhythm. Sleep complaints such as insomnia and cognitive impairments are prevalent in BC. In general population, sleep is known to contribute greatly to cognition. Thus, improving RAR (and particularly sleep) could help limiting cognitive impairments in BC patients. It has recently been suggested that, in addition to its essential role in spatial memory, the vestibular system contributes to RAR synchronization. Its stimulation could therefore limit both sleep disturbances and spatial memory deficits in BC.

OBJECTIVES

The main aim of the ICANSLEEP-2 study is to assess the effects of galvanic vestibular stimulation (GVS) on circadian rhythms. The secondary aim is to assess whether GVS improves sleep and spatial memory in BC patients.

METHODS

Two groups with insomnia complaints (Insomnia Severity Index > 7) will be included: a patients' group with BC (n = 50) and a healthy control group without history of cancer (n = 25). There will be two assessment sessions, before and after 2 weeks of GVS. Patients will be randomly assigned to either a GVS group or a sham group (noneffective stimulation). Controls will receive GVS. GVS effects will be quantified and compared between groups. Assessments will include actigraphy, salivary cortisol, polysomnography, a cognitive test battery (including a computer-based task for spatial memory) and validated questionnaires (for psychological functioning and sleep complaints).

DISCUSSION

Current methods for improving sleep in BC have had controversial outcomes regarding sleep structure. We expect GVS to offer a new mean of directly targeting RAR disruptions in BC patients, with beneficial effects on sleep structure. Given the crucial impact of sleep on cognitive functioning, notably spatial memory, improving sleep of BC patients should enhance their cognitive functioning.

ETHICS AND DISSEMINATION

This study received ethical approval from the Ile de France IV institutional review board on 19 April 2022 (no. ID-RCB: 2022-A00437-36). The findings yielded by this protocol will be presented at various conferences and in peer-reviewed journals.

CLINICALTRIALS.GOV REGISTRATION NUMBER

NCT05414357.

Medication use for the management of professional performance: between invisibility and social normalisation

This article aims to explore pharmaceuticalisation processes in professional work contexts. The approach focuses on identifying patterns of medicine and dietary supplement use for managing work performance, and on discussing the relationship between these consumption practices and work-related pressure factors. This analysis adapts the notions of 'normalisation' to understand the extent of cultural acceptability of these practices, and the notion of 'differentiated normalisation' to capture the tension between the trend towards normalisation of such consumption and its partial social (in)visibility within work settings. Empirical support for this analysis is based on a sociological study conducted in Portugal on professions under high performance pressures. The study involved three professional groups - nurses, journalists and police officers. A mixed methods approach was used, including focus groups, questionnaires and semi-structured interviews. Overall, the results show a trend towards the use of medicines and supplements for performance management, which reveals itself as a cultural response to work-related social pressures. Such consumption coexists with irregular patterns of either occasional or long-term use, as well as heterogeneous processes of 'normalisation' and 'hidden' consumption. Conclusions point to a social interconnection between the intensification of work pressures and the pharmaceuticalisation of work performance.

Healthcare Professionals' Discursive Constructions of Parental Vaccine Hesitancy: A Tale of Multiple Moralities

Healthcare professionals play a crucial role in addressing the concerns of vaccine-hesitant parents since they form a trusted source for vaccine-related information. An increasing body of evidence suggests that healthcare professionals are faced with complexities when navigating the sensitive topic of parental vaccine hesitancy, as they balance their own vaccine- and context-specific concerns with institutional and societal pressures to vaccinate. Furthermore, health choices, such as parental choices for childhood vaccination, are often linked to moralisation. Given the emphasis on effective communication with vaccine-hesitant parents in the patient-centred care literature, it is important to consider healthcare professionals' interpretations of parental vaccine hesitancy. Hence, a deeper understanding of how healthcare professionals make sense of, and moralise, childhood vaccination can help us understand how moralisation might appear in their communication with hesitant parents (in)directly. Drawing on a critical social-psychological framework for discourse analysis, this study analyses 39 semi-structured interviews with healthcare professionals in Flanders, Belgium, and presents the discursive patterns articulated by healthcare professionals on parental vaccine hesitancy. The findings elucidate how healthcare professionals perpetuate, or resist, moral discourse in their accounts of vaccine hesitancy by constructing five different interpretative repertoires, that is, a "good" or "bad" parenting repertoire, a freedom of choice repertoire, an individual risk-benefit repertoire, a public health repertoire, and an accessibility repertoire. Our study highlights the complexities healthcare professionals experience in negotiating vaccine hesitancy, as their understandings of vaccine hesitancy are affected by, and contribute to, existing moral dilemmas and dominant discourses surrounding health and parenting.

From prescribing dilemma to knowledge in practice: The ontological politics of benzodiazepines and Z-drugs

The discrepancy between official guidelines and clinical practice is hardly more pronounced than in the case of benzodiazepines and Z-drugs, also known as benzodiazepine receptor agonists (BZRA). Using social-constructionist positioning theory, we unravel how health care professionals deal with the dilemma of prescribing this medication. Our results reveal a prescribing spectrum that is discursively organised around four different storylines used by professionals. The storylines are organised along three axes that are related to a) prescribers' opinions on prescribing and the negotiation of the related risks, b) the power dynamics between provider and patient in the prescribing process and c) the rhetorical use of arguments. The discerned storylines allow us to explore the emotional and moral side of prescribing and demarcate clinical mindlines -internalised tacit guidelines-that professionals adhere to when they prescribe. By relying on Annemarie Mol's conceptualisation of ontological politics, we explain how these storylines enact multiple versions of this class of medication and justify seemingly contradictory prescribing practices.

And they slept happily ever after: Online interpretive repertoires on the use of benzodiazepines and z-drugs

Drawing on a critical social-psychological framework for discourse analysis, data from a popular forum for people over 50 were analysed to study how the habitual use of benzodiazepines and Z-drugs (BZD/Z) is discursively negotiated by Flemish older adults. We present five different repertoires (risk and addiction; alternative pathways; suffering; rationalisation; cessation) that illustrate how a pharmaceutical imaginary of these medications is constructed online and how posters act as reflexive users taking on a health role. Most repertoires emerge from a tacit norm on the undesirability of medication use for sleeping problems. In the alternative pathways and cessation repertoires this norm is implicitly accepted by focussing on how to either prevent or overcome chronic use with various alternative solutions or through tapering off, while the risk and addiction repertoire is used to more openly defend and discursively magnify the idea that medication has to be avoided at all cost. We discuss how this reflects a prevailing imperative of health and ethos of healthicisation of sleep. The rationalisation and suffering repertoires on the other hand challenge this norm by defending medication use. We further explore how these repertoires are used to self-position as either 'noble non-user', 'deserving and/or compliant patient' or 'rational user', reflecting previously found moral positions in offline settings. Our data add another position that has thus far not been discussed extensively with regard to prescription medication use, namely that of a 'recovered user'. As such, this study shows how this particular online community is a site for contestation of health promotion and medical/pharmaceuticalised discourses on sleep by users and non-users alike and offers a unique insight into how people in the age group that is known to use most BZD/Z discursively negotiate the use of these medications in pseudonymised online interactions.

Wrangling for health: Moving beyond 'tinkering' to struggling against the odds

This article proposes and outlines a new metaphor - 'wrangling for health'- to think about the health seeking efforts occurring within the complex and exhausting everyday realities of resource-poor communities. It draws on fieldwork carried out in a rural community in Sri Lanka (in 2019) with the aim of generating data on the therapeutic practices and health seeking activities of 20 households in the face of everyday ill-health matters. For people in such resource-poor communities, achieving a 'good' health outcome(s) means a constant and ongoing struggle against the challenges of a low-income household, inhospitable healthcare settings and a diverse therapeutic landscape. Based on my findings, I present four key trends in this struggle: a) negotiating the costs and economies of healthcare, b) seeking treatment only as a desperate measure, c) navigating the diverse therapeutic alternatives and d) circumventing the system. These give a glimpse into the ongoing and painstaking efforts by which people creatively mobilise and manipulate whatever resources accessible to them, balance the pros and cons of potential outcome(s) and persevere courageously against adverse circumstances. As such, the struggle for health mirrors their ongoing struggle to 'tie it up together' or wrangle it in everyday life ("jeewithaya gatagaha-gannava"). Wrangling for health - in its sense of struggling against the odds - is therefore proposed as a metaphor for health engagements that challenge the notion of 'tinkering' (Mol, 2008; Mol et al., 2015) so as to depict more accurately the broad range of health seeking efforts that occur within the diverse healthcare landscapes around the world.

Sleep pattern and predictors of daily versus as-needed hypnotics use in middle-aged and older adults with insomnia

Introduction

This study aims to examine the sleep pattern and predictors of daily vs. as-needed use of hypnotics in middle-aged and older adults with insomnia.

Methods

Patients aged 50–75 who use hypnotics for insomnia were identified via electronic medical records and were recruited. Data about sociodemographics, mood and cognitive screening measures, and questions related to sleep patterns were collected through an interview conducted over the phone.

Results

A sample of 66 participants was recruited, of which 69.7% were females. Three quarters (49/66, 74.2%) used hypnotics daily, with 43% (21/49) of daily hypnotics users sleeping more than 8 h per night. Two-fifths (26/66, 39.4%) of participants still had clinically significant insomnia even after taking hypnotics. After adjusting for age, years of hypnotics use, sleeping hours per night, PHQ-2 score, and frequency of pain at night, the logistic regression model showed that younger age (p = 0.023) and longer sleeping hours per night (p = 0.025) were significantly associated with daily hypnotics use when compared to as needed hypnotics use.

Conclusion

Many hypnotic users still have clinically significant insomnia and poor quality of sleep as reflected by perceived longer sleep duration and more daytime napping which could be related to drug-related residual sedation. Hypnotic use may not be the best solution for insomnia treatment in an older population, and physicians should regularly reassess the use of hypnotics.

The pharmaceuticalisation of life? A fictional case report of insomnia with a thought experiment

Background

The safety of sleeping pills has increased dramatically during the last 100 years, from barbiturates to bensodiazepines to modern day so-called Z-drugs.

Methods

The circumstances of prescribing sleeping pills in the early 20^th century are illustrated by summarizing the main storyline of a novel by Swedish writer Vilhelm Moberg. This is followed by a thought experiment and a theoretical discussion.

Results

In his 1937 novel Sömnlös (Swedish for sleepless) Vilhelm Moberg portrayed existential and relational distress in relation to insomnia. In a thought experiment, past progresses in sleeping pills safety are projected into the future. Thereby, it is claimed that important issues in the area of philosophy of medicine come to the fore. This leads to a theoretical discussion about broader questions concerning the role of the physician, the goals of medicine (as described by Lennart Nordenfelt), the concept of pharmaceuticalisation (as described notably by sociologist of sleep Simon J. Williams and co-workers), and health enhancement (c.f. Carl Elliott and the alleged wish to be better than well).

Conclusion

Insomnia is a prism through which important philosophical and sociological questions related to the practice of medicine can be asked.

Sleep, body work and bodily capital: Sleep discourse in the magazines Men's Health and Women's Health

The subject of sleep has been receiving increasing attention in multiple arenas over the past decades, including in the social sciences and the media. However, only a few empirical studies have investigated how sleep is constructed within and by media discourses, and also whether and how these discourses are gendered. The present article explores how two popular lifestyle magazines, Men's Health and Women's Health, construct sleep. The analysis of online articles reveals that both magazines constitute sleep as a form of body work that enhances bodily capital, but they do so in gendered ways that reinforce patriarchal norms and expectations. This study shows that the magazines' discourse supports the neoliberal project, while also highlighting the malleability and adaptability of neoliberal discourses. The conclusion is that the ways in which the magazines' discourse constructs sleep might deepen both gender and class inequalities.

Dependence on hypnotics: a comparative study between chronic users of benzodiazepines and Z-drugs

Objective:

To evaluate dependence among chronic benzodiazepine and Z-drug users in Brazil.

Methods:

Chronic users of benzodiazepines (n=94), Z-drugs (n=74), or both (n=11) were recruited from the community, underwent a psychiatric evaluation and completed self-report instruments on hypnotic dependence, insomnia, anxiety, and depression. Users of benzodiazepines and Z-drugs were compared using t-tests, and logistic regression models were employed to explore significant predictors of a dependence diagnosis.

Results:

There was no difference in the prevalence of dependence among benzodiazepine (77.2%) and Z-drug (69.4%) users. Benzodiazepine users reported increased psychosocial aspects of dependence, anxiety, and depression. Preoccupation with the availability of medication (prevalence ratio [PR] = 2.39 [1.15-5.20]) and insomnia (PR = 1.10 [1.02-1.19]) were associated with a diagnosis of dependence (n=175).

Conclusion:

The prevalence of dependence was similar among both drug classes. The increased self-reported dependence, anxiety, and depression among benzodiazepine users may be due to behavioral rather than pharmacological aspects of medication use. Behaviors related to hypnotic use were important predictors of dependence.

Patterns of Concomitant Prescription, Over-the-Counter and Natural Sleep Aid Use over a 12-Month Period: A Population Based Study

STUDY OBJECTIVES

Concomitant patterns of sleep aid use may provide insight for understanding the transition to chronic sleep medication use. Therefore, we sought to characterize the trajectories of concomitant natural product (NP), over-the-counter (OTC), and prescribed (Rx) sleep aid use in a population-based sample over 12-months.

METHODS

Self-reported data on the use of NP, OTC, and Rx sleep aids were extracted from a Canadian longitudinal study on the natural history of insomnia (N=3416, M age = 49.7±14.7 years old; 62% women) at baseline, 6 months and 12 months. Latent class growth modeling was used to identify latent class trajectories using MPlus 7. Participants completed a battery of clinical measures: Ford Insomnia Response to Stress Test, abbreviated Dysfunctional Beliefs and Attitudes about Sleep Scale, Beck Depression Inventory, Insomnia Severity Index and, the Pittsburgh Sleep Quality Index. Associations between class membership and baseline covariates were evaluated.

RESULTS

Concurrent sleep aid use fell into six distinct latent class trajectories over a 12-month period: Minimal Use (74.5%), Rx-Dominant (11.3%), NP-Dominant (6.3%), OTC-Dominant (4.3%), Rx-NP-Dominant (2.4%), and Rx-OTC-Dominant (1.1%). The three latent classes with prominent prescribed agent use predicted greater incidence of healthcare professional consultations for their sleep (p< 0.05), poorer sleep quality (p< 0.001), elevated dysfunctional sleep beliefs (p< 0.001), and sleep reactivity (p< 0.001). Compared to the other four latent classes, clinical profiles of Rx-NP-dominant and Rx-OTC-dominant groups endorsed greater severity across measures.

CONCLUSIONS

Patterns of sleep aid use may provide insight for identifying individuals who may be vulnerable to inappropriate self-medicating practices.

Psychometric properties of the Benzodiazepine Dependence Self-Report Questionnaire - Portuguese Version (BENDEP-SRQ-PV)

Objective

To assess psychometric properties of the Benzodiazepine Dependence Self-Report Questionnaire – Portuguese Version (BENDEP-SRQ-PV) in a sample of Brazilian chronic hypnotic users.

Methods

One hundred and seventy-nine chronic hypnotic users (benzodiazepines and Z-drugs) were recruited, attended a psychiatric evaluation, and answered the BENDEP-SRQ-PV. Factor structure, reliability, and influence of covariates (dependence diagnosis and type of drug consumed) were assessed in a structural equation modelling environment. Discrimination was assessed with receiver operating characteristic (ROC) plots and stability with the test-retest method.

Results

Participants, mostly women (91.6%), aged 51 to 64 years old, had been using hypnotics for an average of 34.8 months, with a mean defined daily dose of 0.72. Psychometric analysis demonstrated construct and criterion validity, reliability, and response stability. The factor structure was maintained as originally proposed: problematic use (ω = 0.73), preoccupation (ω = 0.74), lack of compliance (ω = 0.74), and withdrawal (ω = 0.93).

Conclusion

The BENDEP-SRQ-PV is an adequate measure of hypnotic dependence in the Brazilian population of chronic users. Our results support using the scale for follow-up in clinical and research applications and in correlational studies.

"You have to do something": Snoring, sleep interembodiment and the emergence of agency

Although the sociology of sleep is a growing subfield, little is known about agency in the context of sleep. This article contributes to the sociological literature by showing how different types of agency emerge as a result of sleep interembodiment (i.e., experiencing sleep partners' bodies as intertwined). The study draws on qualitative data generated through in-depth interviews with 70 snorers and 20 sleep partners of snorers. Interviews were conducted in Israel and were analysed following constructivist grounded theory principles. Results indicate that two types of agency coexist and, in fact, co-constitute one another: The first type, herein termed material agency, reflects the post-humanist tradition, which conceptualizes agents as entities (whether human or nonhuman) that alter a state of affairs by making a difference in another agent's action. This type of agency exists in both wakefulness and throughout periods of sleep, as the snorer's body acts and interacts with a partner's body in ways that engender significant change in their lives, relationships, and actions. In contrast, the second type, herein termed reflexive agency, reflects the humanist tradition, which regards agency as individuals' creative and assertive capacities motivated by intentionality and reflexivity. This type of agency declines significantly during stages of deep sleep but re-emerges in response to partners' actions. The article adds to the literature by refining the concept of agency and elucidating its relationship to both accountability and interembodiment. In addition, the article provides much-needed empirical evidence showing how "personal responsibility" for health, as required by neoliberal discourses, is invoked within families, specifically with regard to sleep. This study therefore shows how certain macro-level structures of neoliberalism are enacted and reinforced within micro-level interactions.

Beyond Treatment Versus Enhancement: A Qualitative Study of Pharmacological Neuro-Enhancement Among Dutch and Lithuanian University Students

This article examines the ambiguous relationship between treating illness and enhancing normalcy through the use of “cognitive enhancement” drugs. Although the literature on pharmacological neuro-enhancement generally differentiates between the “licit/therapeutic” and “illicit/enhancement” use of substances, in-depth interviews with 35 university students in the Netherlands and Lithuania—both with and without formal medical diagnoses of (mainly) Attention Deficit Disorder and Attention Deficit Hyperactivity Disorder—reveal the fluidity of these categories. Our study of the perceptions and experiences of people who use such drugs further suggests a much broader range of substances, motives, and sought-after effects than are commonly acknowledged in the “cognitive enhancement” literature. We need a more inclusive and context-sensitive approach to study pharmacological neuro-enhancement, for instance, by approaching both licit and illicit drugs as tools or instruments.

Maintaining masculinity: Moral positioning when accounting for prostate cancer illness

This article explores men's experiences following treatment for prostate cancer through the lens of chronic illness. Recent empirical work suggests prostate cancer may be better understood as a chronic illness. Prostate cancer offers a case study to examine how older men's masculinities are disrupted by chronic illness experience. Qualitative interviews with 29 men, recruited from two prostate cancer support groups, explored prostate cancer and post-treatment experiences. Men's experiences are examined by drawing on the works of Steve Robertson and Kathy Charmaz for understanding masculinities in relation to health and illness. Aspects of chronic illness experience are identified in men's accounts, particularly concerns with loss of moral status resulting from ongoing and potentially stigmatising treatment side effects. Four forms of moral positioning are identified that align with Steve Robertson's empirically derived model theorising the relationship between health and hegemonic masculinity. These findings facilitate discussion of the interaction between chronic illness experience, morality and masculinities, providing insight into how older men maintain their masculinity in the wake of illness.

Medicalisation, pharmaceuticalisation, or both? Exploring the medical management of sleeplessness as insomnia

In this paper we examine the medical management of sleeplessness as 'insomnia', through the eyes of general practitioners (GPs) and sleep experts in Britain. Three key themes were evident in the data. These related to (i) institutional issues around advocacy and training in sleep medicine (ii) conceptual issues in the diagnosis of insomnia (iii) and how these played out in terms of treatment issues. As a result, the bulk of medical management occurred at the primary rather than secondary care level. These issues are then reflected on in terms of the light they shed on relations between the medicalisation and the pharmaceuticalisation of sleeplessness as insomnia. Sleeplessness, we suggest, is only partially and problematically medicalised as insomnia to date at the conceptual, institutional and interactional levels owing to the foregoing factors. Much of this moreover, on closer inspection, is arguably better captured through recourse to pharmaceuticalisation, including countervailing moves and downward regulatory pressures which suggest a possible degree of depharmaceuticalisation in future, at least as far prescription hypnotics are concerned. Pharmaceuticalisation therefore, we conclude, has distinct analytical value in directing our attention, in this particular case, to important dynamics occurring within if not beyond the medicalisation of sleeplessness as insomnia.

Developing expertise, customising sleep, enhancing study practices: exploring the legitimisation of modafinil use within the accounts of UK undergraduate students

Introduction and aim: Increasing numbers of students are reportedly using prescription medications to enhance cognition. This study aimed to generate qualitative data on UK students' understandings and perspectives of the risks and benefits surrounding so-called 'study drugs' (particularly, modafinil). Design and methods: Fifteen undergraduate students studying biomedical science subjects were interviewed about their perspectives on study drugs. Interviews were recorded and transcribed for thematic analysis. Users and non-users were included in the sample. Results: The prescription status and comparisons to other legal and illicit stimulants informed accounts of the (lack of) risks associated with study drugs, legitimising use. The customisation of sleep(iness) and wakefulness was described as a key benefit of study drug use. Drivers of use related to university pressures and desires to increase productivity. In periods of heightened stress, such as examinations, students reported altered practices and perspectives on risk. Discussion and conclusions: We noted the contextual nature of students' use and risk appraisals, with fluctuating social contexts and pressures over time being capable of altering prior assessments and current practices (including the legitimisation of study drug consumption). Further, we highlighted the degree to which students leveraged their biomedical and experiential expertise to account for drug consumption.

Patient Perceptions of Treatment Delivery Platforms for Cognitive Behavioral Therapy for Insomnia

OBJECTIVE

Stepped care has given rise to the proliferation of abbreviated CBT-I programs and delivery formats. This includes interventions delivered by allied health professionals and those delivered electronically through the Internet. This article aims to explore patient perceptions between electronic and face-to-face (FTF) delivery platforms for (abbreviated) CBT-I.

PARTICIPANTS

Patients with insomnia from specialist sleep or psychology clinics and those from the general community in Sydney, Australia.

METHOD

Semistructured interviews were conducted with patients with insomnia, guided by a schedule of questions and a choice task to explore patient perceptions of the different CBT-I treatment delivery platforms (e.g., perceived advantages and disadvantages or willingness to engage with either platform). Interviews were transcribed verbatim and analyzed using Framework Analysis. Participants also completed a battery of clinical mood and insomnia measures.

RESULTS

Fifty-one interviews were conducted with patients with insomnia from specialist sleep or psychology clinics (n = 22) and the general community (n = 29). Synthesis of the qualitative data set revealed three themes pertinent to the patients' perspective toward electronic and FTF CBT-I delivery: Concepts of Efficacy, Concerns About Treatment, and Treatment on My Terms. Participants' choice to engage with either platform was also informed by diverse factors including perceived efficacy of treatment, personal commitments, lifestyle, and beliefs about sleep and insomnia.

CONCLUSION

Clarifying patient treatment priorities and allaying potential concerns about engaging with an electronic treatment platform represent important steps for disseminating eCBT-I into mainstream practice.

Mapping the illness trajectories of insomnia: a biographical disruption?

The insomnia illness experience can be conceptualised as a form of biographical disruption. Using a critical interpretive phenomenological lens 51 in-depth semi-structured interviews were conducted with patients from specialist sleep and psychology clinics (n = 22) and the general community (n = 29). Patients' narratives revealed key phases of their illness trajectories as they recognise, rethink and respond to insomnia. Their biographical events served as reference points for both patient groups to make sense of their illness experiences as they transitioned from a perceived state of sleeplessness to clinical insomnia. The innate biological process of sleep at night and the sleep-dependent daytime psychosocial function exerted a negative bi-directional effect, creating a continuous circuit of disruption. Coping mechanisms were inspired by the participants' immediate social environment and centred on sociocultural motifs of relaxation and alertness to break the 'circuit'. Access to specialist clinic services appeared to be contingent on the richness of resources in one's social network and surrounding environment rather than the clinical severity of the disease alone. Treatment that can simultaneously target the night time and daytime consequences of insomnia resonates closely with participants' depiction of insomnia as both a physiological and a psychosocial phenomenon.

What is wrong with 'being a pill-taker'? The special case of statins

In an interview study of decision-making about statins, many participants said they took pills regularly, yet described themselves as 'not really pill-takers'. This paper explores this paradox and its implications. The practice of pill-taking itself can constitute a challenge to the presentation of moral adequacy, beyond the potential for rendering stigmatised illnesses visible. Meeting this challenge involves a complex process of calibrating often-conflicting moral imperatives: to be concerned, but not too concerned, over one's health; to be informed, but not over-informed; and deferential but not over-deferential to medical expertise. This calibration reflects a broader tension between rival tropes: embracing medical progress and resisting medicalisation. Participants who take statins present them as unquestionably necessary; 'needing' pills, as opposed to choosing to take them, serves as a defence against the devalued identity of being a pill-taker. However, needing to take statins offers an additional threat to identity, because taking statins is widely perceived to be an alternative strategy to 'choosing a healthy lifestyle'. This perception underpins a responsibilising health promotion discourse that shapes and complicates the work participants do to avoid presenting themselves as 'pill-takers'. The salience of this discourse should be acknowledged where discussions of medicalisation use statins as an example.

Pharmaceuticalisation and the social management of sleep in old age

This paper discusses sleep as a social phenomenon, analysing it in the older population within the frame of a growing pharmaceuticalisation of conditions associated with old age. Two analytical dimensions are privileged: one pertains to patterns of sleep in old age, showing these patterns to be socially differentiated; while another has to do with the subjective experience of sleep, particularly in terms of the social meanings attributed to sleep as well as the strategies employed to manage it. These strategies may be therapeutic or non-therapeutic, as an expression of different rationales favouring or resisting the pharmaceuticalisation of sleep. This analysis is empirically based on data from a research project on the consumption of psychopharmaceuticals among the older population, in an urban context in Portugal. The research methodology followed a mixed-methods approach: a survey was deployed to a sample of individuals aged 65 years and over (N = 414); and life history interviews were conducted with a number of respondents (N = 30) from the previous survey. Both techniques included individuals with physical and cognitive autonomy, living at home or in institutional settings. The results reveal a considerable social adherence to the use of pharmaceuticals to manage sleep problems, although consumption practices are socially differentiated in terms of gender, age and living contexts. They also reveal the use of non-therapeutic strategies, stemming from a resistance to the pharmaceuticalisation of sleep.

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

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.