Clinical reviewPrevalence, associated factors and management of insomnia in prison populations: An integrative review
Introduction
In the United States, nearly 1% of the adult population is incarcerated at any one time [1]. It has been estimated that the majority of prisoners have some type of mental disorder ∗[2], [3], [4], [5]. While much work has focused on mental health and physical comorbidity in prison populations (see [2] for review), there has been comparatively little research on insomnia specifically, either as a symptom of these disorders or a disorder in its own right. Crucially, the prison context may both directly interfere with sleep-wake regulation and present a barrier to effective management of sleep disturbance.
General population studies report that around a third of people experience general insomnia symptoms and between 5 and 15% experience clinically defined insomnia disorder (ID) [6], ∗[7]. This wide prevalence range reflects the differing definitions of insomnia and the variety of assessment tools adopted by different studies [8]. In terms of agreed definitions of insomnia, all three commonly used sleep classification manuals accept that the main symptoms of insomnia are a persistent problem initiating or maintaining sleep; experiencing early morning awakenings; and/or non-restorative sleep [9], [10], [11]. To obtain disorder status at a clinical threshold, daytime functioning such as concentration, work productivity and mood must be adversely affected. The most widely accepted risk factors for insomnia are: being female [12]; increasing age [13], [14], [15]; and comorbid physical and psychiatric disorders [7]. Insomnia can negatively impact on quality of life [16] and is a risk factor for the future onset of cardiovascular disease, depression and anxiety disorder and even mortality [17]. However, hypnotic medication (e.g., zopiclone, zolpidem, diazepam etc.) [18] and non-pharmacological treatments (e.g., cognitive behavioural therapy (CBT) etc.) [19], [20], [21] can improve insomnia, health and non-health related quality of life symptoms [16].
Around 90% of prisoners have some sort of mental disorder including personality and substance misuse disorders [22]. The high prevalence of mental disorder, physical health problems, substance misuse issues and prescription medications within prison settings may also compound premorbid sleep disturbances, given the recognised relationship between sleep and health [3], [4], ∗[23], [24]. Due to the nature of the prison regime normal sleep-wake patterning may be affected through interruption of usual daily routines [25]; forced contact with others [26]; fear of violence [27]; and lack of autonomy [28]. Features of the physical environment are also likely to confer further disturbance to sleep-wake regulation including exposure to extreme hot or cold temperatures [29]; experiencing too much or too little light [30]; excessive noise [30], [31] (e.g., cell doors slamming, prisoners shouting, keys jangling etc.); and inadequate bedroom setup (e.g., poor mattress quality) [32]. It is not known what non-pharmacological interventions for insomnia are offered across the prison estate internationally, however some general interventions have been recommended in the United Kingdom (UK) policy literature, including psychological therapies, lavender, milky drinks and sleep hygiene advice as preferable to prescribing medication [28].
There has been only one other review conducted in this area to date. In a scoping review published in 2007, Elger [33] asked three research questions: 1) are sleep complaints in prisoners caused by substance misuse, post traumatic stress disorder and mental disorder including insomnia; 2) is insomnia situational; and; 3) what is the importance of reactive anxiety and depression due to being imprisoned compared to prison environmental factors (e.g., light, noise etc.). The review included nine research studies in its analysis, however inclusion and exclusion criteria were not identified and there was no objective evaluation of study quality. Thus there remains the need for an up-to-date rigorous review, which examines these factors. Therefore, in this integrative review we collate, describe and discuss the available insomnia-prison literature, identifying key themes for research and practice. The paper will critically reflect on the method and quality of conducted studies, and outline a thorough research agenda, delineating a series of studies required to further elucidate the prevalence and management of insomnia in prison settings.
Section snippets
Methodology
Systematic reviews and meta-analyses rigorously assess research evidence, usually concentrating on gold standard studies including randomised controlled trials (RCTs). There was a clear lack of RCTs in this area therefore an integrative review method was chosen. This approach permits an integrated assessment and comparison of many different research methods (e.g., experiment, semi-structured interview etc.), regardless of design [34]. An integrative review routinely consists of five stages of
Overview of evidence
Overall, using Hawker et al.'s checklist, seven studies were rated as good ∗[22], [39], [40], ∗[41], [42], [43], [44], twenty-one as fair [45], [46], [47], [48], ∗[49], [50], [51], [52], [53], [54], [55], [56], [57], [58], [59], [60], [61], [62], [63], [64], ∗[65] and five as poor [66], [67], [68], [69], [70]. The studies that were rated as poor mainly had an inadequate introduction and/or lacked clear research questions or objectives and limited explanation of the methodology and the sampling
Discussion
The methodical approach used in this review has resulted in a cutting edge assessment of the prison related insomnia literature. Five main themes were yielded by the review; prevalence; co-morbidity, including the complex relationship between insomnia, anxiety, depression and substance misuse; the impact of situational factors and the prison environment itself; prescription medication; and finally, the possible impacts of non-pharmacological treatment options.
Insomnia and/or sleep problems were
Conclusion
This is the first integrative review to examine insomnia in a prison population. In conclusion, despite the publication of a number of scientific papers, rigorous research surrounding the prevalence, aetiology and management in a prison population is rare. Treatment decisions are frequently made more difficult in prison due to the prison environment and because prisoners with insomnia are more likely to have comorbid disorders which impact upon treatment options and likely efficacy.
Conflicts of interest
None to report.
Acknowledgements
This paper was supported by the University of Manchester studentship grant for research and the Medical Research Council (MRC) MR/K500823/1.
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