International Journal of Psychiatry in Clinical Practice, 2009; 13(3): 206
217

ORIGINAL ARTICLE

Prospective evaluation of insomnia in prison using the Pittsburgh Sleep Quality Index: Which are the factors predicting insomnia?

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BERNICE S. ELGER1 & EVA SEKERA2 1

University Center of Legal Medicine of Geneva and Lausanne, Switzerland; 2Centre Envol, Fondation Fe´nix for the Treatment of Drug Addicts, Gene`ve, Switzerland

Abstract Objectives. To measure the subjective sleep quality of prisoners complaining of insomnia and to compare it to the subjective sleep quality of prisoners who report "good sleep", in order to determine factors that predict insomnia and severity of insomnia. Participants and methods. PSQI and GHQ scores and patient history were obtained for 86 randomly chosen remanded prisoners complaining of insomnia and 61 randomly chosen prisoners who did not complain of insomnia. Results. PSQI total and component scores were significantly different between insomniac and not insomniac prisoners, except for C7 (daytime dysfunction). A history of sleeping problems before prison (odds ratio: 13.3), the subjective experience of having had stressful events during the past week (odds ratio: 8.5), being separated or divorced (odds ratio: 8.8), GHQ
10 (odds ratio: 8.8), a history of psychiatric problems (odds ratio: 8.3) and the consumption of opiates (odds ratio: 7.9), and to a lesser degree ‘‘no sports in prison’’ and stress related to judicial, familial and prison problems, were predictors of insomnia. We did not find any evidence in this study that work or consumption of caffeine in prison were factors that distinguished good sleepers from insomnia patients. Conclusions. Our study helps prison physicians to identify prisoners at risk for insomnia and to obtain some orientation for treatment decisions. Psychological support to reduce context related stress should be routinely offered to insomniac prisoners.

Key Words: Prison, insomnia, PSQI

Introduction Many prisoners complain of insomnia [1
3]; The extent to which environmental, psychosocial, and sociocultural factors may contribute to insomnia in prison or its prevention has so far not been targeted by empirical studies [4]. The following reasons have been proposed: the high percentage of substance misusers in the prisoner population [5
7] who suffer from insomnia as part of withdrawal symptoms, the higher prevalence than outside prison of psychiatric illnesses [6,8
12], psychological or psychiatric symptoms resulting from imprisonment such as increased distress, anxiety and depression [13,14], and environmental conditions of detention such as solitary confinement, noise, lack of physical activity, heat, cold and boredom [1,15,16]. We have shown [17] that prisoners in the canton of Geneva received about 10 times more hypnotics and anxiolytics than non-

prisoners attending a medical policlinic in the same region. These differences persisted when the comparison was limited to patients who were not known to be substance misusers. In another study [18] we have estimated the overall prevalence of insomnia complaints at the Geneva remand prison out patient clinic to be 44.3%. Fifty-one percent of the insomnia patients were drug misusers. The most frequently reported reason for insomnia was anxiety related to incarceration. A comparison between the records of the 112 non-substance abusing insomniac patients and the 103 non-insomniac non-substance abusers showed that a higher percentage of insomnia patients than of non insomnia patients had a history of medical and psychiatric illness, suffered from anxiety or depression in prison, and received prescriptions of psychotropic and analgesic medications. We are not aware of any study measuring sleep quality of prisoners in an operationalised way and

Correspondence: Professor Bernice S. Elger, MD PhD, MA (theol.), Institut universitaire de me´decine le´gale, 9 Av. de Champel, 1211 Geneva 4, Switzerland. Tel: 41 22 379 5589/5600. Fax: 41 22 789 2417. E-mail: [email protected]

(Received 17 June 2008; accepted 10 February 2009) ISSN 1365-1501 print/ISSN 1471-1788 online # 2009 Informa UK Ltd. DOI: 10.1080/13651500902812043

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Evaluation of insomnia in prison using the PSQI that tries to define the influence of different factors by comparing good and bad sleepers. The aim of the present study was therefore to fill this gap, i.e. to describe the subjective sleep quality of prisoners complaining of insomnia prospectively in an operationalised way and to compare it to the subjective sleep quality of prisoners who report ‘‘good sleep’’, in order to determine factors that predict insomnia and severity of insomnia. Knowing these factors could help prison physicians to discover whether additional interventions would be useful to improve insomnia. Our hypotheses were that being alone in a cell, having already been in prison and thus knowing the environment, work and sport activities and low intake of stimulating beverages or chocolate would decrease the risk of suffering from insomnia or at least decrease its severity whereas recent stressful events would increase it. In addition we were interested in knowing how many of prisoners complaining of insomnia have already suffered from and taken medication for an insomnia problem before arriving at the prison, how many had a history of psychiatric problems, and how many suffer from other medical problems, or problems related to substance abuse. Patients and methods The remand prison in Geneva where the study took place has originally been constructed for 270 detainees. During the study period there was chronic overcrowding. When the number of prisoners was constantly rising up to 400 during the 1990 (and reached 500 in 2006), prisoners worked in wood ateliers and produced beds that were then fixed on top of the existing beds to provide bunk beds. This permitted to change the typical 8-m2 one-bed cell into a two-bed cell and the somewhat bigger two-bed cells into three
four-bed cells. This means that there are about 4 m2 of cell space per prisoner. The prison is a modern concrete building without noteworthy noise insulation. Noise is therefore significant during the nocturnal rounds by prison guards. In addition, television in the cells causes significant disturbances to detainees who would like to sleep earlier than some of their cell mates. The heating system in the prison was unreliable when the study took place. Some cells were well heated and others were too cold. The bunk beds have average mattresses and bedding. All prisoners have access to one hour per day of outdoor activities. During this hour they can exercise on their own or practice sports. Work hours in the Geneva remand prison are from 08:00 to 10:45 in the morning and from 13:30 to 16:00 in the afternoon. Work activities are under the supervision of a few trained craftsmen employed by the prison

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and prisoners are running almost all kitchen and cleaning work and are also employed in most of the painting and construction work needed in the prison. Some contracts with outside business exist, e.g., for book binding and the taking to pieces of computers. Pottery and products of the prison bakery are sold on special, e.g., ‘‘art’’-markets. Working places are limited in the Geneva remand prison and can only be provided to about one in five detainees. Prisoners have to be on a waiting list for about 3 months before getting a work opportunity. This means that most detainees spend 23 out of 24 hours in their cells. During the study period, there were about 3000 primary care physician consultations per year in the remand prison. After having received training concerning the research instruments, five research assistants employed in clinical work at the prison medical service from February 1999 until March 2000 and from August 2003 until April 2004 conducted personal interviews with 86 prisoners randomly chosen among all prisoners asking for medical consultation because of insomnia (about every 10th patient asking for insomnia consultation during the study period). The interviews were conducted just before the medical consultation scheduled in the usual way (in general several days to 1 week after a written demand of the prisoner). In order to obtain a control group of prisoners without insomnia, we took a random sample from patients who, according to their medical records (almost all prisoners who stay in prison at least 1 month have been seen by a doctor at least once) had been in prison at least 1 month without having complained of insomnia (the random process was the following: every 3 days medical records were screened from patient whose names started with the same letter, including eventually the entire alphabet). Prisoners received a written invitation explaining the research project and their right to refuse participation. If they consented to consultation at the medical service, the research assistant explained the project orally and asked prisoners to sign written consent forms. Of the 88 prisoners asking for insomnia consultation two had to be excluded because of language difficulties. All other 86 participated in the study. In the control group, of 81 inmates who received invitations because they were identified as free of insomnia complaints based on the medical records, two refused to discuss with the research assistant, and two more refused participation. Of the remaining 77, 16 complained of insomnia. The remaining 61 did not consider themselves to suffer from insomnia and were included in the control group of ‘‘good sleepers’’. The protocol was approved by the University Hospital of Geneva’s Ethics Committee for Studies Related to Public Health.

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Data were collected using two standardised research instruments. The Pittsburgh Sleep Quality Index [19] was used to measure sleep quality and its different components (C1 subjective sleep quality, C2 sleep latency, C3 sleep duration, C4 habitual sleep efficiency, C5 sleep disturbances, C6 use of sleeping medication, C7 daytime dysfunction). The PSQI has been shown to provide a reliable, valid (polysomnography and clinical psychiatric evaluation as gold standard), and standardised measure of sleep quality, to discriminate between‘‘good’’ and ‘‘poor’’ sleepers and to provide a brief, clinically useful assessment of a variety of sleep disturbances that might affect sleep quality. In our version of the PSQI the estimate period was reduced from 4 weeks to 1 week, because the 4-week period was too long for patients recently arrived and because of the rapidly changing conditions of imprisonment. Others have shown that test
retest reliability of the PSQI using shorter estimate periods is high in primary insomnia [20]. In order to measure psychiatric symptoms among the insomniac patients, we used Goldberg’s (1978) [21] 28-item General Health Questionnaire (GHQ) and the 0011 scoring method. The GHQ-28 [22
25] is a scaled 28-item version of the original GHQ-60 and has been used and validated previously in prisoners [13,26,27]. In accordance with Andersen [26], for the original scoring procedure of 0011 for all items [21,22], a GHQ total score of 10/11 is considered the threshold for a psychiatric case. Validation of the GHQ among remanded prisoners has shown that adopting these threshold scores is more adequate than the usually used threshold of 5/6 and leads to the best balance between specifity and sensitivity [26]. All subjects also answered questions about their medical and psychiatric history, their history of insomnia and use of sleeping and other medication and of illicit drugs and alcohol before entering prison, as well as questions relating to their habits in prison: consumption of any drugs, coffee, tea, etc., physical activity, type of work, and the presence of particular stress and its type. Due to the international character of the prison population, interviews were conducted in four languages (French, German, English and Spanish [13]). Statistical analysis was performed using SPSS (14.0). We compared the self reported good sleepers to the prisoners who asked for consultation because of a sleep problems using Student t-tests (components of the PSQI scores) and chi-square tests (dichotomic characteristics and sleep related details). Binary logistic regression was used to determine which variables predict insomnia among the 147

patients and stepwise linear regression (univariate analysis of variance) entering variables significant at the 5% level was used to test which variables predict the severity of insomnia among the 86 patients who asked for medical consultation because of insomnia. Results Among the 77 detainees identified as not having complained of insomnia during previous medical visits, 16 reported having sleep problems at the time of the interview and the remaining 61 said that they have no sleep problem (referred to as ‘‘good sleepers’’). The 16 prisoners who had not asked for medical consultation because of insomnia but who reported a sleep problem at the interview and the 86 patients seen on consultation for insomnia complaints did not differ significantly in sociodemographic variables and in all sleep-related variables tested, except that the 16 prisoners had lower scores in the C3 (sleep duration) and C4 (sleep efficiency) components scores and a lower reliability of the PSQI than the 86 patients. Characteristics and conditions of imprisonment of the participants The 86 prisoners who had asked for medical consultation because of insomnia had entered prison a minimum of 4 days and a maximum of 782 days before the interview (median 31, mean 67, SD 104 days). ‘‘Good sleepers’’ and insomniac prisoners had similar demographic characteristics, except that a higher percentage of bad sleepers was divorced or separated (Table I, P 0.02). Medical and drug history were significantly different. Although the percentage of good and bad sleepers who had suicide attempts in the past was similar (10
15%), bad sleepers had more often a psychiatric history, including psychiatric hospitalisation, and had more often visited general practitioners before imprisonment. Prisoners complaining of insomnia in prison showed higher consumption of tranquillisers, hypnotics and illicit drugs before imprisonment and a higher percentage had a history of sleeping problems than good sleepers (Table II) and were smokers (Table III). Conditions of imprisonment were similar, except for the following issues: an important difference was found in the prevalence of self-reported worries about the offence and judicial procedures and of events perceived as stressful: a higher percentage of bad sleepers than good sleepers reported to experience stressful events at the moment of the interview. In addition, less bad sleepers than good sleepers practiced sports in prison. Bad sleepers reported a higher degree of sadness than good sleepers and a higher

Evaluation of insomnia in prison using the PSQI

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Table I. Comparison of characteristics (mean [SD] or number and %) of 86 prisoners randomly chosen among patients having asked for medical consultation because of insomnia and 61 randomly chosen prisoners without insomnia (‘‘good sleepers’’).

Characteristics

Good sleepers

N Age Women n (%) Separated/widowed n (%) Single n (%) Married or ‘‘with somebody’’ Height of patient (cm) Weight of patient (kg) BMI Nationality: Swiss Other Europe Africa Other (America, Asia, etc.) Days in prison at the interview First imprisonment (%)

61 27.2 [99.5] 4 (6.6%) 1 (1.8%) 48 (78.7%) 7 (12.5%) 177 [9 7] 74.9.1 [9 13] 24.1 [9 3.5] 3 (4.9%) 26 (42.6%) 19 (31.1%) 13 (21.3%) 50.4 [9 21] 24 (39.3%)

Insomnia patients having asked for consultation 86 29.1 6 11 58 17 174 71.5 23.7 11 33 32 12 66.5 33

[9 9.5] (7.0%) (12.8%) (67.4%) (19.8%) [9 7] [9 12] [9 3.3] (12.8%) (38.4%) (37.2%) (14.0%) [9 104] (38.4%)

P*

0.24 0.92 0.02 0.13 0.18 0.04 0.11 0.47 0.11 0.60 0.45 0.24 0.16 0.89

*Student t-test for continuous variables, x2 for dichotomic variables.

percentage of the former than the latter received methadone and hypnotics in prison (Table III). Subjective sleep quality of participants Scores for the different components of the PSQI were available for all 147 subjects. The seven component scores of the PSQI had an overall reliability coefficient of 0.83 (0.83 in [19]). ‘‘Good sleepers’’ and the 86 insomniac prisoners differed significantly in all components (C1
C7) and the global PSQI score. The global PSQI score of insomniac prisoners (12.894.0) was similar to the scores found by Backhaus et al. [20] for patients suffering from primary insomnia (12.593.8). Compared to depressive and DIMS patients [19], insomniac prisoners had higher values for sleep latency, sleep duration, sleep efficiency, and use of sleeping medication, and lower values for daytime dysfunction (Table IV). ‘‘Good sleepers’’ went to bed at the same average time than insomniac prisoners and had a similar getting up time (Table V). Significant differences between good sleepers and insomniac prisoners are shown in Table V. No significant differences were found for the number of hours spent in bed, and for the trouble sleeping related to coughing or snoring or feeling cold. About one-third of both groups took a nap of similar mean duration (25
33 min). GHQ scores of insomniac prisoner patients The GHQ was completed by 123 prisoners (reliability: 0.92). Table VI shows that adopting validated threshold scores (GHQ total severity
10, Andersen

et al. 2002), 37% of prisoners complaining of insomnia, but only 6% of good sleepers would be considered a psychiatric case. Adopting threshold scores of 12/13 [13] 26% of insomniac prisoners had high levels of psychiatric symptoms at the interview. The highest scores were obtained for the sub-scale ‘‘anxiety and insomnia’’, and the lowest scores for the depression sub-scale. Variables predicting insomnia Binary logistic regression of the variable ‘‘insomnia versus no insomnia’’ among the 147 patients showed that a history of sleeping problems before prison (odds ratio: 13.3, Table VII), the subjective experience of having had stressful events during the past week (odds ratio: 8.5), being separated or divorced (odds ratio: 8.8) and a history of psychiatric problems (odds ratio: 8.3) were all predictors of insomnia when entered separately. The odds ratios of different explanatory models implying other variables such as ‘‘no sports in prison’’, stress related to judicial, familial and prison problems, and the consumption of opiates are shown in Table VII.

Discussion Most important findings Insomnia is an important health problem in prison. However, nothing is known about its types, reasons and treatment strategies that would directly act on the causes. In this respect, our study has several interesting findings.

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Table II. Comparison of medical and drug history (in liberty before imprisonment) of 86 prisoners randomly chosen among patients having asked for medical consultation because of insomnia and 61 randomly chosen prisoners without insomnia (‘‘good sleepers’’).

Characteristics:mean [SD] or number (%)

Good sleepers

Number of consultations§ with general practitioner Number of consultations§ with psychiatrist or phychotherapist Number of consultations§ with physician from other specialties History of psychiatric hospitalisation Psychiatric history History of suicide attempt History of sleeping problems outside prison Has been taking in liberty: Analgesics (%) Frequency of analgesics consumption& Hypnotics (%) Frequency of hypnotics consumption& Tranquillisers (%) Frequency of tranquillisers& Has taken BZD before prison Has been drinking alcohol (%)# Frequency of high alcohol consumption& Cannabis (%) Frequency of cannabis consumption& Opiates (heroin) (%) Frequency of opiates (heroin)& Cocaine (%) Frequency of cocaine consumption& Intravenous use of illicit drugs Other illicit drugs: ecstasy, LSD, amphetamines (%) Frequency of consumption of other illicit drugs (ecstasy, LSD, amphatamines)& Consumption of tranquillizers or illicit drugs except cannabis Cons. of tranquillizers or illicit drugs (with cannabis) and OH**

0.3 0.08 0.07 0 2 6 5 32 0.7 4 0.08 4 0.05 2 43 1.2 24 0.8 3 0.1 9 0.2 0 6 0.07

[9 0.6] [90.6] [9 0.3] ( ) (3.3%) (9.8%) (8.2%) (52.5%) [9 0.8] (6.6%) [9 0.3] (6.6%) [9 0.2] (3.3%) (70.5%) [9 1.0] (39.3%) [9 1.4] (4.9%) [9 0.5] (14.8%) [9 0.6] ( ) (9.8%) (9 0.3)







14 (23.0%) 30 (49.2%)

Insomnia patients having asked for consultation 0.9 0.1 0.2 8 19 13 37 45 0.6 31 0.7 21 0.6 24 42 1.1 45 1.0 25 0.6 34 0.8 11 16 0.2

[9 2.4] [9 0.6] [9 0.7] (9.3%) (22.1%) (15.1%) (43.0%) (52.30%) [9 0.6] (36.0%) [9 1.1] (24.4%) [9 1.1] (27.9%)£ (48.8%) [9 1.2] (52.3%) [9 1.1] (29.1%) [9 1.1] (39.5%) [9 1.1] (12.8%) (18.6%) [0.5]

40 (46.5%) 58 (67.4%)

P* 0.03 0.7 0.14 0.02 0.001 0.3 B0.001 0.99 0.5 B0.001 B0.001 0.005 B0.001 B0.001 0.009 0.8 0.12 0.4 B0.001 B0.001 0.001 0.001 0.003 0.14 0.04 0.004 0.03

*Student t-test for continuous variables, x2 for dichotomic variables, significant differences (P50.05) bold. § During the past 3 months before imprisonment. & Frequency of consumption: every day (score 3), two or three times/week (score 2), less than twice/week (score 1), never (score 0). £ Of the 18 patients (34.6%) who have taken BZD, 11 (21.2%) took one BZD, three (5.8%) took two BZD, and four (7.7%) took three BZD. # More than 2l beer or 1l wine/day. **OH, alcohol every day (quantity see #).

First, the PSQI enabled us to describe better different components of the reported insomnia. We found important significant differences between the subjective sleep quality of prisoners who complained of insomnia and of prisoners who considered themselves as good sleepers. In comparison to insomnia patients outside prison, the component 7 (daytime dysfunction) was somewhat lower. This might be due to the fact that it is more difficult to evaluate daytime dysfunction in prison since being in their cells most of the time (in a remand prison, most prisoners do not work), prisoners do not have to complete difficult tasks that could be compromised by fatigue. Our findings might also somewhat reassure the prison physician. Prisoners do not think that insomnia has as severe consequences as one could imagine, such as severe lack of concentration during court audiences and other activities that might influence the judicial proceedings. In addition,

these results suggest that insomniac prisoners have described their sleeping problems in a differentiated way. This could indicate that insomniac prisoners responded honestly without in general exaggerating complaints. Second, our study helps clarifying the possible reasons for insomnia in prison. History of insomnia before prison, psychiatric history, the consumption of BZD and tranquillizers in liberty and illicit drug use, especially opiates, were important predictors of insomnia in prison. However, another important reason appeared to be the stress resulting from the judicial procedure, from the prison conditions and from relationship problems due to the social situation. Insomniac prisoners differed from good sleepers, in that the great majority of the former (91%) reported such stressful events in general and two thirds of the insomniacs, compared to 18% of the good sleepers, reported particularly stressful events

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Evaluation of insomnia in prison using the PSQI

Table III. Comparison of conditions of imprisonment, consumption of drugs, and other habits (in prison) of 86 prisoners randomly chosen among patients having asked for medical consultation because of insomnia and 61 randomly chosen prisoners without insomnia (‘‘good sleepers’’).

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Characteristics mean [SD] or number (%)

Insomnia patients having asked for consultation

Good sleepers

Living alone (in one-bed-cell) 4 (6.6%) 2.7 [9 1.0] Number of roommates£ Smoking 32 (52.5%) No. of cigarettes/day in prison 7.0 [9 9.6] Use of illicit drugs in prison 3 (4.9%) Cups of coffee/day in prison 1.6 [9 2.3] Chocolate (g/day) in prison 20.8 [9 27.4] Cups of tea/day 1.4 [9 1.7] Glasses of coke/day in prison 1.0 [9 3.9] Sports (football, fitness room) in prison 50 (82.0%) Hours of sports in prison 0.8 [9 0.6] Working in prison 13 (21.3%) Did you have particularly stressful events during the 11 (18.0%) past week? Stress in general reported:# 41 (67.2%) a) in relation to law pursuit a) 14 (23.0%) b) private (relational, financial) b) 21 (34.4%) c) in relation to prison conditions (isolation, violence) c) 10 (16.4%) Did you feel sad during the past week?§$ 1.4 [1.0] Have you been worrying about your offence/judicial 1.3 [1.0] procedure?§ Taking medication in prison: Antidepressant treatment 0 (
) Pain medication 2 (3.3%) Methadone 0( ) Hypnotics (except herbal) 4 (6.6%) Herbal hypnotic 0 (
) Neuroleptic treatment 1 (1.6%)

P*

14 2.8 61 9.7 3 1.1 14.7 1.9 0.5 50 0.5 18 56

(16.3%) [9 1.2] (70.9%) [9 10.1] (3.5%) [9 1.4] [9 31.9] [9 2.3] [9 0.9] (58.1%) [9 0.7] (20.9%) (65.1%)

0.08 0.6 0.02 0.12 0.7 0.13 0.2 0.12 0.3 0.004 0.06 0.99 B0.001

79 a) 46 b) 50 c) 33 1.8 1.8

(91.9%) (53.5%) (58.1%) (38.4%) [1.0] [1.2]

B0.001 a) B0.001 b) 0.005 c) 0.004 0.03 0.02

3 (3.5%) 4 (4.6%) 6 (7.0%) 42 (48.8%) 7 (13.5%) 4 (4.6%)




0.14 0.6 0.02 B0.001 0.2 0.3

*Student t-test for continuous variables, x2 for dichotomic variables, significant differences (P50.05) bold. £ Number of prisoners in the same cell (the prisoner participant himself included) § 36 good sleepers and 79 insomnia patients reported reasons, some reported more than one reason. Possible answers: not at all (score 0), a little (score 1), somewhat (score 2), very much (score 3). # 36 good sleepers and 79 insomnia patients reported reasons; some reported more than one reason. $ This question were taken from the questionnaire used routinely in the "sleeping laboratory" of Geneva University Hospital.

Table IV. Comparison of the PSQI components of 86 remanded prisoners randomly chosen among patients having asked for medical consultation because of insomnia and 61 randomly chosen prisoners without insomnia (‘‘good sleepers’’). Components (mean [SD]): N C1 Subjective sleep quality C2 Sleep latency C3 Sleep duration C4 Habitual sleep efficiency C5 Sleep disturbances C6 Use of sleeping medication C7 Daytime dysfunction PSQI global score

Prison: good sleepers 61 0.6 [0.6] 0.8 [0.9] 0.3 [0.5] 0.2 [0.6] 1.0 [0.3] 0.02 [0.2] 0.3 [0.5] 3.2 [2.0]

Prison: insomniac patients 86 2.1 [0.7] 2.4 [1.1] 2.2 [1.1] 1.9 [1.3] 1.6 [0.7] 1.7 [1.4] 1.0 [1.1] 12.8 [4.0]

P

B0.001 B0.001 B0.001 B0.001 B0.001 B0.001 B0.001 B0.001

Controls Buysse [19] 52 0.4 [0.5] 0.6 [0.7] 0.3 [0.5] 0.1 [0.3] 1.0 [0.4] 0.04 [0.3] 0.4 [0.5] 2.7 [1.7]

Depression Buysse [19] 34 1.9 [0.9] 1.9 [1.2] 1.7 [1.1] 1.6 [1.2] 1.5 [1.2] 0.8 [1.2] 1.8 [0.7] 11.1 [4.3]

DIMS Buysse [19]

2.0 1.4 1.5 1.5 1.4 1.2 1.4 10.4

45 [0.9] [1.0] [1.2] [1.2] [0.6] [1.3] [0.9] [4.6]

 Comparison of good sleepers with insomniac patients in prison: Student t-test for continuous variables, significant differences (P 50.05) bold; values in the table: mean (standard deviation). DIMS, Disorders of initiating or maintaining sleep.

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Table V. Comparison of the PSQI items and other sleep related questions of 86 remanded prisoners randomly chosen among patients having asked for medical consultation because of insomnia and 61 randomly chosen prisoners without insomnia (‘‘good sleepers’’) Components (mean [SD]):

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PSQI total score
5 PSQI total score
6 Average time going to bed Average getting up time Average hours in bed Time to fall asleep in minutes Hours slept per night During the past week, how often have you had trouble sleeping because you . . . Q0: could not get to sleep within 30 min (1) Q1: wake up in the middle of the night or early morning (1) Q2: have to get up to use the bathroom (1) Q3: cannot breathe comfortably (1) Q4: cough or snore loudly (1) Q5: feel too cold (1) Q6: feel too hot (1) Q7: had bad dreams (1) Q8: had pain (1) Q9: noise/light in prison by guardians/roommates disturbed me (1) Q10: was thinking about my process/crime (1) Trouble staying awake§ (1) Problem to keep up enough enthusiasm to get things done? (2) Number of awakenings/night# Were you tired when waking up in the morning? (3) Have you been afraid of not sleeping? (3) Daily activities affected because of sleeping problem? (3) Takes a nap in prison Mean duration of nap (min) Sleep perceived as regenerative#

Prison: good sleepers 9 4 22:57 7:20 8.2 19 7.7

(14.8%)£ (6.6%)£ [2.1] [1.1] [1.6] [20] [1.5]

0.6 [1.0] 0.5 [0.8] 0.4 [0.6] 0.3 [0.7] 0.5 [1.0] 0.3 [0.8] 0.2 [0.6] 0.5 [0.8] 0.5 [0.9] 0.4 [0.7] 1.0 [1.0] 0.4 [0.8] 0.05 [0.3] 0.6 [0.9] 0.3 [0.6] 0.3 [0.6] 0.1 [0.4] 22 (36.1%) 33 [54] 60 (98.4%)

Prison: insomniac patients 81 80 22:58 7:09 8.1 113 5.0

(94%)$ (93%)$ [2.0] [1.4] [2.5] [123] [1.7]

2.4 [1.2] 2.5 [1.1] 1.2 [1.3] 0.7 [1.2] 0.7 [1.3] 0.6 [1.1] 0.5 [1.0] 0.9 [1.1] 0.9 [1.3] 1.0 [1.4] 2.1 [1.3] 1.0 [1.3] 0.8 [1.1] 1.6 [1.9] 1.8 [1.0] 1.5 [1.1] 1.0 [1.2] 30 (34.9%) 25 [51] 13(15.1%)*

P B0.001 B0.001 0.98 0.36 0.78 B0.001 B0.001

B0.001 B0.001 B0.001 0.007 0.14 0.06 0.01 0.02 0.02 0.001 B0.001 0.001 B0.001 B0.001 B0.001 B0.001 B0.001 0.88 0.3 B0.001

 Comparison of good sleepers with insomniac patients in prison: Student t-test for continuous variables, x2 for dichotomic variables, significant differences (P50.05) bold. $ One prisoner scored 0, one scored 3, three scored 5, one scored 6. £ Five prisoners scored 6, two scored 7, one scored 8, one scored 9. *Valid percent. § During the past week, how often have you had trouble staying awake while watching television, eating meals, or engaging in social activity. (1) Scores: Not during the past week (score 0) to three times or more a week (score 3). (2) During the past week, how much of a problem has it been for you to keep up enough enthusiasm to get things done? No problem at all (score 0), only a very slight problem (score 1), somewhat of a problem (score 2), a very big problem (score 3). (3) Possible answers: not at all (score 0), a little (score 1), somewhat (score 2), very much (score 3). These questions were taken from the questionnaire used routinely in the ‘‘sleeping laboratory’’ of Geneva University Hospital. # These questions were taken from the questionnaire used routinely in the ‘‘sleeping laboratory’’ of Geneva University Hospital.

during the past week (odds ratio 8.5). Moreover, insomniac prisoners, compared to good sleepers, were more often worrying about their criminal offence/judicial procedure and reported trouble sleeping because they were thinking about their process/crime. Somatic health problems played some, though not a very important role: insomniac prisoners, compared to the good sleepers, reported more often trouble sleeping because of pain (P0.02), and because they had to go to the bathroom during the night (P B0.001). However, the latter difference could be the result of different drinking habits, and not of somatic problems. Factors related to the conditions of imprisonment and lifestyle in prison

were less important. Insomniac prisoners reported more frequently trouble sleeping because of noise or light from roommates and guardians (P 0.001) and insomniac prisoners were more often smokers than good sleepers (P 0.02) and only 58% of them, as compared to 82% of the good sleepers, practiced sports in prison (P 0.004). The number of roommates, work in prison, as well as consumption of illicit drugs, coffee, chocolate, tea and coke, did not differ between insomniac and non insomniac prisoners. In addition, our hypothesis that having been previously in prison and thus knowing the environment could have a positive influence on sleep was not confirmed.

Evaluation of insomnia in prison using the PSQI

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Table VI. GHQ scores of prisoners complaining of insomnia (‘‘ins’’ n74), of good sleepers (‘‘gsl’’ n 49) and from a representative sample of all prisoners of the same prison (Geneva, Champ Dollon) at day 10 (T1, n200) and day 60 (T2, n88) in a previous study[13].

GHQ scales

Mean

SD* or 95% confidence intervals**

Somatic symptoms Our study: Insomniacs/good sleepers Previous study T1 (all) Previous study T2 (all)

2.3/0.7 3.4 2.8

1.9*/1.2* 3.2
3.7** 2.3
3.3**

Anxiety and insomnia Our study: Insomniacs/good sleepers Previous study T1 (all) Previous study T2 (all) Social dysfunction Our study: Insomniacs/good sleepers Previous study T1 (all) Previous study T2 (all) Depression Our study: Insomniacs/good sleepers Previous study T1 (all) Previous study T2 (all) Total severity Our study: Insomniacs/good sleepers Previous study T1 (all) Previous study T2 (all)

P (ins vs. gsl)

B0.001

Psychiatric cases (%)$






High§ scoring subjects (%)

Reliability (Cronbach’s a)

32%/6% 50% 40%

0.74 0.76 0.77

43%/6% 64% 52%

0.85 0.82 0.87

31%/6% 48% 32%

0.84 0.76 0.80

11%/4% 30% 30%

0.88 0.84 0.87

26%/6% 57% 43%

0.92 0.90 0.93


3.4/0.6 4.3 3.5

2.1*/1.4* 4.0
4.7** 2.9
4.0**

B0.001







2.2/0.8 3.5 2.6

2.2*/1.5* 3.2
3.8** 2.1
3.0**

B0.001







1.1/0.5 2.5 2.4

1.9*/1.4* 2.2
2.9** 1.9
3.0**

0.04







9.0/2.5 13.8 11.3

6.1*/4.4* 12.8
14.8** 9.6
13.0**

B0.001

37%/6% Not known Not known

$

According to the validation of Anderson: GHQ
10. GHQ28’0011’ scoring method for% high scoring subjects: scores
3, except for total severity, where scores
12.

§

Good sleepers and insomniac prisoners went to bed and rose at about the same time. The higher number of hours that good sleepers slept per night (mean 7.7 h) compared to insomniac patients (mean 5.0 h) is related to a longer sleep latency, a lower sleep efficiency and more frequent awakenings per night. Interestingly, several good sleepers go to bed late and rise late in the morning. However, breakfast in prison is distributed before 08:00 h, and prisoners who have any judicial appointments leave prison at around 08:00 h. Going to bed earlier than about 23:00 h in prison is difficult especially if co-detainees watch television until past midnight, so getting sufficient hours of sleep in prison could imply not eating breakfast or not having to leave prison for judicial reasons. Anticipating anxiety related to insomnia itself seemed to be of some, but minor, importance. Insomniac patients reported mild anxiety (‘‘being afraid of not sleeping’’) with a mean of 1.591.1, i.e. between "little" (score 1) and ‘‘somewhat’’ (score 2). Fear of not sleeping was significantly greater among insomniac prisoners than among good sleepers (mean 0.390.6, PB0.001).

In a previous study, it has been shown that GHQ scores of prisoners in the Geneva remand prison were lower 2 months after imprisonment than 10 days after imprisonment. The GHQ scores of insomniac patients from our study were close to GHQ scores of prisoners after 60 days of imprisonment, except for the subscale depression and the total GHQ score which were somewhat lower. Our GHQ score for insomniac prisoners were all lower than scores of prisoners at day 10 of incarceration [13]. This is in line with the fact that insomniac prisoners from our study reported a mean of 67 days of incarceration at the time of the PSQI interview. The similar GHQ scores indicate that insomniac prisoners do not suffer more from psychiatric symptoms than prisoners in general after a period of adaptation to the prison environment. However, as known for prisoners in general [6,8
13], the percentage of psychiatric cases among insomniac prisoners adopting validated threshold scores (10/11 [26]) was high (37%). Adopting high threshold scores (12/13 [13]), still 26% of insomniac prisoners would be considered a psychiatric case. The GHQ scores of the good sleepers are clearly lower than

Model 1 2 3 4 5 6 7 8 9 10 11

12

13

Variables retained (after single or stepwise entering) -GHQ high scoring 10 (Andersen) -Particularly stressful events during past week  -Consumption in liberty of heroine or cocaine  -Consumption of opiates (heroine etc.) in liberty  -History of sleeping problems before prison  -History of psychiatric problems before prison  -separated or divorced  -Stress related to judicial, familial, prison problems  -Smoking  -History of psychiatric problems§ -no sports in prison -Consumption of opiates (heroin, etc.) in liberty§ -History of psychiatric problems before prison§ -no sports in prison -Hypnotics intake before prison§ -Stress related to judicial, familial, prison problems§ -Smoking§ -History of sleeping problems before prison§ -separated or divorced§ -Stress related to judicial, familial, prison problems§ -Smoking§

*Nagelkerke R2 square.  entered as single variable. § stepwise entering of variables (forward conditional).

Degree of freedom

Patient number

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

147 (or 123) 147 147 147 146 145 147 147 144 143 143

144

143

B

SE

P

2.2 (2.2) 2.1 1.4 2.1 2.6 2.1 2.2 1.7 0.8 2.1 1.1 2.3 1.7 1.2 2.8 2.5 1.1 3.0 2.5 2.4 1.3

0.6 (0.6) 0.4 0.4 0.6 0.6 0.8 1.1 0.5 0.4 0.8 0.4 0.8 0.8 0.4 0.7 0.7 0.4 0.8 1.1 0.7 0.6

0.001 (0.001) B0.001 0.001 0.001 B0.001 B0.006 0.04 B0.001 0.02 0.008 0.006 0.004 0.04 0.006 B0.001 B0.001 0.008 B0.001 0.02 B0.001 0.005

R2* 0.15 (0.17) 0.27 0.11 0.14 0.27 0.11 0.06 0.13 0.05 0.17 0.27

0.4

0.4

Odds ratio (8.8) 8.5 4.0 7.9 13.3 8.3 8.8 5.5 2.3 8.3 3.0 9.5 5.5 3.2 16.8 11.7 3.1 19.6 12.7 11.3 3.8

B.S. Elger & E. Sekera

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Table VII. Binary logistic regression of the dependent variable insomnia (n86) versus no insomnia (n 61).

Evaluation of insomnia in prison using the PSQI seem to be scores of the average detainee in our remand prison and the percentage of psychiatric cases was also low (6%). This, as well as the results of the binary logistic regression, confirm that insomnia is related to general health and especially anxiety in prison.

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Implications of the results of our study for the prison physician Our study helps to identify prisoners at risk for insomnia. Consumption of illicit drugs is clearly a risk factor for insomnia. On the other hand, if one excludes cannabis which is used similarly by around half of the entire sample, this risk factor is only present in 47% of insomniac prisoners, i.e. at least half of insomnia problems cannot be attributed to co-existing problems related to illicit drug abuse. This confirms findings from a previous study [17]. Insomnia in our sample was related to a history of psychiatric problems including psychiatric hospitalisation. Interestingly, the pre-existing psychiatric problems seemed to have been either rather in the remote past or to have been somewhat under-treated at least in the recent past, because no difference was found between the frequency with which good and bad sleepers had seen a physician or a psychiatrist during the 3 months preceding incarceration. This is in line with other studies which showed a low rate of previous health care in prisoners in our neighbour country France [28]. Although a low percentage (3.3%) of good sleepers had a history of psychiatric disease, it should be noted that the history of prior suicide attempts was relatively high among both insomniacs and good sleepers, reported by 10% of good sleepers and 15% of insomniacs. This is a rather high percentage, compared to an incidence of attempted suicide in the general population that has been evaluated at 105 per 100,000 inhabitants in France during the time of our study [29,30] and at 130 per 100,000 inhabitants in Belgium [31]. Insomnia appears to be an indicator of ‘‘psychiatric cases’’, because insomniac prisoners’ GHQ scores differed significantly from those of good sleepers in our study. Interestingly, in the previous study of Harding and Zimmermann, the average GHQ scores of all prisoners after 60 days of imprisonment were very similar to the scores of our insomniac prisoners and not to the scores of our good sleepers. It is possible, that prisoners at the time of this previous study were somewhat generally in worse health than at the time of our study or that Harding and Zimmermann obtained slightly overevaluated GHQ scores in general. This would also explain, why Harding and Zimmermann [13] proposed a 2-point higher threshold for psychiatric

215

cases than Anderson [26]. Our results are in line with Anderson’s scoring given that the percentage of prisoners suffering from insomnia is known to be high. In a previous study we found that around 50% of prisoners who have been seen on consultation at the prison outpatient clinic have spontaneously complained of or were treated for insomnia. In our present study, when trying to identify good sleepers, we were confronted with the fact that the percentage of prisoners suffering from insomnia is higher that those who ask for medical consultation because of insomnia or complain spontaneously during consultation. A substantial number of prisoners, although suffering from insomnia when asked directly, does not seem to communicate this fact to the medical service. Among the possible explanations are the fact that prisoners might find this insomnia ‘‘normal’’ in prison and/or that they would not want medical treatment for this problem. For the prison physician it is of interest that 43% of the insomniac prisoners reported that they already suffered from insomnia before imprisonment. Less of insomniac prisoners, only 36%, said that they had taken hypnotics during the three months preceding incarceration, and even less (28%) reported to have taken BZD during life-time before. Our previous study of the records of all insomnia patients treated at the Geneva remand prison during one year showed that almost all insomniac patients received a prescription of hypnotics from the prison physicians, most of them being BZD or Zolpidem [32]. Similar high percentages of prescriptions of BZD, Zolpidem, or less often, Chloral hydrate have been found in the insomniacs from the present study [33]. The prison physician should be aware that for twothirds of the insomniac prisoner patients this is probably the first contact with BZD and Zolpidem. He/she should inform the patients thoroughly about the limited evidence based benefits of BZD [34] and about risks of dependency. Our study helps prison physicians to judge treatment possibilities more realistically. The relatively small size of our study does not permit to exclude that other factors play a role that cannot be shown in a study of limited power such as ours. On the other hand, most factors that we suspected to be of influence had a considerable size of effect and the differences between good and bad sleepers were very significant. Work in prison did not seem to have a major effect on insomnia problems. However, it must be taken into account that in our remand prison, work opportunities exist only for one fifth of the prisoners population in general. Working hours are closer to a half time job than a full time job in liberty. Most of the work is indoors in ateliers and does not require physical force in particular. It is

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B.S. Elger & E. Sekera

remarkable that the great majority of good sleepers (82%) and still 58% of insomniacs report sports activities in prison. Our study suggests that practicing sports in prison could improve sleep problems, as it is known from the literature [35,36]. However, our study design does not permit to exclude that the lower percentage of sports activities of insomniac patients is at least to some extent a consequence of the fatigue resulting from insomnia. A more detailed analysis of sports and leisure activities of the prisoners from our study can be found elsewhere [37]. Prison physicians should be aware of the importance of context related stress. Influencing judicial procedure or relational problems of prisoners is outside physicians’ reach. Offering psychological support in form of short supportive therapies, based on cognitive behavioural therapy methods, could help to reduce subjective stress, but would require considerable resources [38]. Furthermore, our study shows that a thorough history of pain complaints is useful in order to recognise patients who could benefit from more adequate analgesic treatment to prevent insomnia. Our study also provides a basis for prison physicians to discuss the possibility of providing one-bed cells to insomniac prisoners and of trying to find ways to reduce noise, because although good sleepers seemed to sleep well independently of the number of roommates, many prisoners complained of noise and light of guards or co-detainees. Providing more flexible breakfast times might also have a positive effect on insomnia. The costs for ongoing treatment of insomnia as a whole might be greater than costs to achieve some adaptation of the prison environment. Our study has some methodological limitations: the main limitation is the small sample size, especially the smaller number of good sleepers. However, the aim of our study was not to test for factors that have a small effect, but to orient physicians and prison administrators towards factors that have substantial effects on insomnia. Our study results rely entirely on self-reported facts. These might not sufficiently reflect reality. However, we have used validated questionnaires (PSQI, GHQ) and we have no reason to believe that prisoners gave biased responses. Last not least, the sampling in our study was done with an interruption of 2
3 years. However, prison conditions, the functioning of the medical service and the methodology used were the same during the entire period of recruiting and comparisons between the samples included during the two periods do not indicate any socio-demographic or other important differences.

Key points Insomnia is an important health problem in prison. The most important factors predicting insomnia in our study were a history of sleeping problems before prison, reporting the experience of stressful events during the past week, being separated or divorced, a history of psychiatric problems, the consumption of opiates, and to a lesser degree ‘‘no sports in prison’’ and general stress related to judicial, familial and prison problems. “ The PSQI is useful to describe different components of insomnia in prisoners and to distinguish between good sleepers and insomniac patients. “ Insomnia complaints in our sample were an indicator of general health and ‘‘psychiatric cases’’ as defined by scores of the general health questionnaire. “ Influencing and/or treating context related stress as well as improving sleep relevant prison conditions should be part of the medical treatment of insomniac prisoners. “

Financial disclosure Funding was provided by a research fund of the Faculty of Medicine, University of Geneva. Acknowledgements We thank the Professor T.W. Harding for his support. Conflict of interest The authors have no conflict of interest with any commercial or other associations in connection with the submitted article.

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