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Reference

Insomnia in places of detention: a review of the most recent research

findings

ELGER, Bernice Simone

Abstract

Up to 40% of prisoner patients in a general medicine outpatient service seek medical

consultation for sleep problems. This paper provides a brief overview of what is known about

insomnia and its treatment from studies on non-detained patients and discusses the relevance

of the findings from studies in liberty for prison health care. The clinical and ethical issues of

insomnia in prison are described, followed by a summary of the existing studies on insomnia

in prison. The results of the reported studies show that insomnia in places of detention should

not be reduced to a secondary problem related to substance abuse and mental illness, as it

appears to be an independent situational problem. Correctional health care physicians'

evaluation of insomnia is insufficient. Drug prescription works well in some patients, but has a

limited effect on insomnia relief in others. A clear need exists for the education of prison

health care professionals on insomnia evaluation and management. Additional

non-pharmacological treatment in the prison health care setting should be used more

frequently. Prison health care services should develop clear guidelines based on research

evidence about insomnia and which contain treatment recommendations based [...]

ELGER, Bernice Simone. Insomnia in places of detention: a review of the most recent research

findings. Medicine, Science and the Law, 2007, vol. 47, no. 3, p. 191-199

PMID : 17725232

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Insomnia in places of detention: a review of the most recentresearch findings

Bernice S. Elger, MD PhD, MAVisiting Scholar, University of Pennsylvania Medical School

Correspondence: Dr. Bernice S. Elger, Institut universitaire de medecine legale, 9, av. de Champel,

1211 Geneva 4, Switzerland Email: [email protected]

ABSTRACTUp to 40% of prisoner patients in a general medicineoutpatient service seek medical consultation forsleep problems. This paper provides a brief overviewof what is known about insomnia and its treatmentfrom studies on non-detained patients and discussesthe relevance of the findings from studies in libertyfor prison health care. The clinical and ethical issuesof insomnia in prison are described, followed by asummary of the existing studies on insomnia inprison.

The results of the reported studies show thatinsomnia in places of detention should not bereduced to a secondary problem related to substanceabuse and mental illness, as it appears to be anindependent situational problem. Correctionalhealth care physicians’ evaluation of insomnia isinsufficient. Drug prescription works well in somepatients, but has a limited effect in completelyrelieving insomnia in others.

A clear need exists for the education of prisonhealth care professionals on insomnia evaluationand management. Additional non-pharmacologicaltreatment in the prison health care setting should beused more frequently. Prison health care servicesshould develop clear guidelines based on researchevidence about insomnia and which contain treat-ment recommendations based on the principle ofequivalence of health care outside and inside placesof detention.

INTRODUCTION

Although insomnia is a frequent reason formedical and psychiatric consultation inprisons, studies on insomnia in correctionalinstitutions are rare. Most studies on insomniahave targeted patients or populations inliberty (Bixler et al., 1979; Mellinger et al.,1985; Ford and Kamerow, 1989; GallupOrganization, 1991; Hohagen, 1996; Kupferand Reynolds, 1997; Ohayon, 2002; Leopando

et al., 2003; Sateia and Nowell, 2004; Ohayonand Lemoine, 2004). In this article, a briefoverview is provided of what is known aboutinsomnia and its treatment from the studies onnon-detained patients and the relevance of thefindings from studies in liberty for correctionalhealth care is discussed. The clinical andethical issues of insomnia in prison aredescribed, followed by a summary of theexisting studies on insomnia in prison. Con-clusions from studies in liberty and in places ofdetention will be drawn on how insomniashould be dealt with in correctional healthcare and recommendations on worthwhilefurther studies of these issues in prisonmedicine are given.

INSOMNIA: GENERAL RESEARCHFINDINGS

According to numerous studies, the prevalenceof insomnia symptoms ranges from 10% to 48%in the general population of western Europe(Ohayon, 2002; Ohayon and Lemoine, 2004).In France, where 19% of the general popula-tion was found to suffer from insomnia, two-thirds of them reported repercussions on day-time functioning (Ohayon and Lemoine, 2004).A similar prevalence is found in the US.Insomnia is a persistent problem in approxi-mately ten per cent of US Americans. One-third of the adult population in the UnitedStates has suffered at least once during theirlife from a sleep problem. In Europe and theUS, higher rates of insomnia are seen inwomen, people who are less educated or

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unemployed, separated or divorced indivi-duals, medically ill patients, those with recentstress, and those suffering from depression,anxiety, or substance abuse (Bixler et al., 1979;Mellinger et al., 1985; Ford and Kamerow,1989; Gallup Organization, 1991; Hohagen,1996; Kupfer and Reynolds, 1997; Leopando etal., 2003; Sateia andNowell, 2004; Ohayon andLemoine, 2004).

Several classifications of sleep disordersexist of which the most widely known are theInternational Classification of Sleep Disorders(ICSD) 1990, the DSM-IV (APA, 2000) classi-fication and the ICD-10 (WHO, 1992). TheDSM-IV classification distinguishes primarysleep disorders, dyssomnias (getting the rightamount, quality of sleep) which includeprimary insomnia, primary hypersomnia, andnon-specified dyssomnia related to environ-mental factors (noise, light, frequent distur-bances). Further listed categories of sleepdisorders are parasomnias (e.g. sleepwalkingdisorder), sleep disorders due to a generalmedical condition, sleep disorders related toanother mental disorder, most typicallydepression, anxiety or psychosis (the mentaldisturbance must be sufficiently severe), and,finally, substance induced sleep disorders.

According to Sateia and Novell (2004), thesubjective perception of insomnia is at least asimportant as the objective alterations in sleeppatterns and, therefore, the disorder is bestassessed and treated with this idea in mind.

Acute (short term) insomnia (< 3-4 weeks) ismost often related to situational stress, med-ical or psychological disorders and circadianchanges due to jet lag or shift work. Interven-tions are mainly indicated to alleviate theacute stress, to educate patients and tointroduce short-term treatment strategiescomprising sleep hygiene and, when necessary,hypnotics.

With regard to chronic insomnia (>4 weeks),a pharmacological approach has dominatedtreatment choices in the past. The effective-ness of hypnotic drugs is well-established forshort-term treatment of acute insomnia. How-ever, effectiveness of long-term treatment isnot proven. Most studies lasted less than sixweeks. The effects found in short-term

pharmacotherapy trials seem to degrade overtime in patients with chronic insomnia. Inaddition, many health care professionals fearpotential side effects of hypnotics, as well asthe risk of habituation and tolerance (Kupferand Reynolds, 1997).

Non-pharmacological treatments have beenfound to result in long lasting and clinicallysignificant improvement. This is the case ifthese treatments are use alone or accompaniedby pharmacological treatment. Patients suffer-ing from secondary insomnia problems, i.e.insomnia attributable to medical or psychiatricillness, benefit from non-pharmacologicaltreatments as will patients with primaryinsomnia. Most non-pharmacological treat-ments are based on cognitive-behaviouralmethods. They can be used as single orcombined approaches and taught to indivi-duals or groups during therapeutic sessions orusing self-administered written or audio-visual material. Examples of these treatmentsare stimulus control therapy, sleep restriction,sleep hygiene, paradoxical intention, progres-sive muscle relaxation, and cognitive therapy(Spielman et al., 1987; Morin et al., 1994, 1999;Murtagh and Greenwood, 1995; Edinger et al.,2001; Backhaus et al., 2001; Sateia andNowell, 2004).

INSOMNIA IN PLACES OF DETENTION

The most important research questionsA French study has examined the effects of lifeconditions in detention (Association Lyonnaisede Criminologie et d’Anthropologie Sociale,1991). Clearly, these conditions as well as thedifficult experience of imprisonment play animportant role concerning the prevalence ofsleep disturbance complaints (Zimmermannand von Allmen, 1985; Harding and Zimmer-mann, 1989; Vasseur, 2001; Elger, 2004a;Vasseur, 2001; Ross and Richards, 2002; Elger,2004a; Feron et al., 2005). Post-traumaticstress disorder (PTSD) is present in a sizeablenumber of prisoners and is also known to causeinsomnia Krakow et al, 2004; DeViva et al.,2004). Other factors are pre-existing psychiat-ric morbidity, drug misuse, the lack of physicalactivity and daytime napping (Bourgeois,1997; Andersen et al., 2000). The subjective

2 Med. Sci. Law (2007) Vol. 47, No. 3


impression of insomnia might also have beenrelated mainly to the boredom (Levin andBrown, 1975) felt during long periods whenthe cells stay closed at night, making prisonersfeel that they should sleep longer than theyneed from a physiological point of view.

Many questions persist regarding the pre-valence, causes and types of insomnia in placesof detention as well as the efficacy of differenttreatment strategies. Typical questions war-ranting more research are:

(i) Are most sleep complaints of prisonerscaused by secondary insomnia due tosubstance abuse and PTSD, as well aspre-existing psychiatric disorders, includ-ing pre-existing insomnia?

(ii) Is insomnia mostly ‘situational’?

(iii) How important are new psychologicalsymptoms such as reactive anxiety anddepression related to the incarceration ascompared to environmental conditionssuch as noise, light, promiscuity, violenceand rape?

Answering these questions is important inorder to define the most adequate and efficientmanagement strategies. In this respect, it isalso important to know how correctionalhealth care professionals evaluate and treatinsomnia and what the outcomes of theirmanagement are.

Existing studies in the prison environmentthat provide answers to the researchquestions

Studies have been obtained through a search inMedline, on the National Commission onCorrectional Health Care (NCCHC) website(NCCHC, 2005) and the three journals oncorrectional health care that are accessiblethrough this website but which are not listedin Medline, as well as a search for booksthrough Amazon. The used search terms were:sleep, sleep problems, sleep disorders, insom-nia, hypnotics, prison, correctional. The searchyielded only one study carried out in the US(Rogers et al., 2003), and several studies fromEurope (Last, 1979; Jaeger andMonceau, 1996;Elger et al., 2002; Elger, 2003; Lekka et al.,2003; Elger, 2004a, 2004b; Feron et al., 2005).

Epidemiology of insomnia in places ofdetention

Published studies on epidemiology concerninginsomnia and hypnotics prescriptions comefrom Germany, France, Belgium and theremand prison ‘Champ-Dollon’ in Geneva,Switzerland. A study in Germany (Last,1979) found that 54% of all the inmates of theprison in Straubing complained about sleepproblems. Among prisoners older than 50years, sleep complaints were noted less fre-quently, in only 43% of these detainees.

Jaeger and Monceau (1996) have conductedseveral studies on the epidemiology of hypno-tics and anxiolytic medication prescriptions inFrance. First, they obtained the prescriptionstatistics from pharmacies of 99 detentioncentres. These centres were responsible for31,845 detainees from a total of 52,000 in-dividuals detained in France at the time of thestudy. The results indicated that most pre-scribed psychotropic drugs were benzodiaze-pines and sedative neuroleptics. Both types ofsubstances counted for two-thirds of all pre-scriptions distributed by the pharmacies. Acloser analysis of the data showed a greatvariation of the quantity of psychotropic pre-scriptions in different places of detention.Fewer hypnotics and tranquillizers were pre-scribed in the post-trial detentions centres(‘prisons’ in US terminology) than in theremand prisons (US: ‘jails’) included in thestudy. In addition, fewer prescriptions of thesedrugs were found in detention centres wheremore activities were offered, such as work orthe possibility to practice sports.

A retrospective study in Belgium (Feron etal., 2005) examined the use of primary careservices by prisoners from all 33 prisons inBelgium, including remand prisons. The studyincluded 513 patients over a total of 182patient years. The most common reasons forprimary care consultations were administra-tive procedures (22%) followed by psychologi-cal problems (13.1%). Psychological reasonsfor consultations (n=481) involved mainly(71%) feeling anxious, sleep disturbance, andprescription of psychoactive drugs. Sleep dis-turbances accounted for about 20% of thepsychological problems. The limitation of this



study is related to the fact that only primarycare consultations were examined. It is notknown how many prisoners had seen apsychiatrist because of sleep problems. How-ever, it is probable that prisoners who saw ageneral practitioner for sleep problems, andnot a psychiatrist, were those who did notshow evidence of any psychiatric illness andwere suffering mainly from ‘situational’insomnia.

The studies from Switzerland come from asingle remand prison in Geneva that has anaverage population of 300 to 400 inmates andprovides about 3000 outpatient primary careconsultations per year. About 90% of themedical consultations during one year wereincluded and concerned 995 patients. Thisstudy found that insomnia is a frequentcomplaint: 44.3% of the 995 patients werefound to suffer from insomnia, of whom 51%(n=223) were drug misusers (Elger, 2004a).The most frequently reported reason forinsomnia was anxiety related to incarceration.A further analysis of the records of the non-substance-abusing insomnia patients indi-cated that chronic forms of insomnia weremore common than transitory insomnia, de-fined as lasting less than three weeks. A higherpercentage of the insomnia patients than ofnon-insomnia patients suffered from anxietyor depression in prison, had a history ofmedical and psychiatric disease, and receivedprescriptions of psychotropic and analgesicmedications. It was concluded from this studythat in non-substance-abusing patients, in-somnia is not just a transitory problem ofadaptation to incarceration, but amore chronicproblem lasting more than three weeks andrelated to a higher degree of medical andpsychological problems, mainly during incar-ceration.

INSOMNIA AND PSYCHIATRIC DISEASE

A study conducted in the US (Rogers et al.,2003) is interesting concerning the possiblecauses of insomnia, in particular whether theprevailing type of insomnia in places ofdetention is insomnia secondary to substanceabuse or other chronic pre-existing or newpsychiatric disorders. Rogers et al. (2003)

employed the Schedule of Affective Disordersand Schizophrenia-Change Version (SADS-C)in two US American correctional samples andcarried out a validation of the subscales. Thisinstrument has four subscales: (i) dysphoria,(ii) psychosis, (iii) mania, and (iv) insomnia.Rogers et al. (2003) recommend that psychol-ogists use these four dimensions in screeningpatients for prominent Axis I symptoms. Thesubscales help to evaluate patients’ keysymptomatology.

Rogers et al. (2003) found that they weresurprised by the emergence of the insomniasubscale as a separate dimension. Theirassumption had been that various phases ofinsomnia would be aligned with the dysphoriasubscale. Why did insomnia form a separatedimension? The authors suggest two non-exclusive explanations. The first is based onnosological considerations which would bevalid both inside and outside places of deten-tion. The findings of the study could beinterpreted as an indicator that, in general,insomnia does not mainly constitute a specificinclusion criterion for particular disorders.Instead, the data suggests that insomnia maybe independent of diagnosis and is not limitedto disorders associated with dysphoria. Thesecond explanation refers to the fact that thestudy has been carried out among detaineesand therefore the conditions of detention play arole. For persons with or without mentaldisorders detained in large metropolitan jails,these conditions represent highly unstableenvironments. As a consequence, many in-mates experience apprehension about theirpersonal safety, resulting in anxiety, hyper-vigilance, and sleep disturbances (Rogers etal., 2003). Therefore, the emergence of insom-nia as a distinct dimension may reflect itssalience in corrections, independent of othersymptom patterns. This study shows thatinsomnia in places of detention cannot beexplained by the hypothesis that it is onlysecondary to, or part of, psychiatric disorders.If it is true that the prison environment causesindependent ‘situational’ insomnia, it seemsunlikely that it will entirely respond to treat-ment indicated for dysphoria and specificpsychiatric disorders.

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Perceptions of correctional officers inFrance: possible factors associated withinsomnia

Jaeger and Monceau (1996) conducted inter-view and questionnaire studies in five remandprisons and a central prison with three sites(Fleury-Merogis, Lyon, and Clairvaux) inFrance. Sixty interviews were carried out withmembers of the prison administration and theopinions of 317 prison officers (‘guards’ or‘wardens’ in US) were obtained from a ques-tionnaire study. The security personnel as wellas the members of the prison administrationexpressed the opinion that the consumption ofhypnotics/tranquillizers by inmates of theirestablishments increases if high numbers ofdetainees have to share the same cell; duringdistressing phases of trial, especially close tothe judgment; when relationships with guardsare bad; and when higher numbers of drugaddicts are incarcerated. These results point tothe existence of at least three factors that arepossible causes for insomnia in places ofdetention:

(1) ‘External’ conditions of detention such asthe number of inmates per cell;

(2) ‘Internal’ reactions to the situation, suchas anxiety related to the trial and angerresulting from conflicts with the securitypersonnel.

(3) Pre-existing conditions characteristic forthe population of prisoners as a whole: thehigh prevalence of drug abuse associatedwith secondary insomnia and dependenceon hypnotics and tranquillizers.

Possible factors associated with insomniaand hypnotics prescriptions according to otherstudies

A study carried out in the Geneva remandprison has examined the prescription of hyp-notics and tranquillizers in comparison with anon-prison outpatient clinic (Elger et al., 2002;Elger et al., 2004). The authors analysedconsultations with general practitioners andone psychiatrist at the outpatient clinic of theGeneva prison, Champ-Dollon, during threeweeks. The total number of consultationsreported was 269 which involved 179 patients.Analysis of the treatment prescribed during

the first consultation of each patient showedthat 41% of the 179 patients did not receiveany psychoactive drug prescriptions, whereasthe majority received either one (30%), two(25%) or three (4%) psychotropic drugs(Bindschedler, 2004). Almost one quarter(24%) of patients were treated by a hypnoticdrug, and 20% by an anxiolytic BZD; 30%received a BZD for a different diagnosis,mostly to treat acute withdrawal symptomsresulting from various forms of addiction,13% received methadone, 4% had an anti-depressant and 8% a neuroleptic medication.

A comparison of the 113 (prison) and 151(urban policlinic) male patients younger than39 years showed important differences con-cerning the quality and quantity of psycho-active prescriptions. Ten times more prisonpatients than patients from the urban poli-clinic received a treatment of benzodiazepines.The differences could not be explained by thehigh percentage of drug addicts in prison sincethey persisted even when considering onlyprisoners who were not known to be streetdrug, alcohol or long time BZD consumers. Thestudy results suggested that factors related tothe prison environment explain the main partof the differences.

Jaeger and Monceau (1996) also conducted102 personal interviews with French detai-nees, whether or not they were suffering frominsomnia. The prisoners interviewed were inpre-trial or post-trial detention in Fleury-Merogis, Lyon, Clairvaux, Saint Paul, SaintJoseph or Strasbourg. During these inter-views, detainees expressed the opinion thathypnotics and tranquillizers are very impor-tant to help them survive their imprisonment.Inmates are convinced that these medicationsreduce suffering, as well as the risk of suicideand violent behaviour, because their experi-ence of taking hypnotics means they are able tosleep at night and are less aggressive andcalmer during the day. Substantial numbers ofprison administrators and security staff ques-tioned in the same country agreed with theviews expressed by the prisoners. According to30% of the prison officers, hypnotics andtranquillizers help detainees tolerate deten-tion; 4%-15% expressed the view that these



medications help detainees to live togetherpeacefully and 4%-12% felt that the hypnoticsand tranquillizers help to maintain discipline.

A Greek study (Lekka et al., 2003) comparedthe characteristics of 192 inmates receivingprescribed benzodiazepines (BZD) in a high-security Greek prison at therapeutic doses and192 inmates without prescriptions of BZD.Although this comparison was carried outindependently of any insomnia complaints,the study provides additional interesting find-ings concerning the characteristics of detai-nees treated with hypnotics or tranquillizersand is therefore reported here. BZD users weresignificantly more often on remand, more oftenunemployed before imprisonment, more oftensingle, divorced, or widowed than non BZDusers. Significantly, more BZD users than non-users appeared to suffer from psychiatricdisease, since a higher proportion of the formerthan the latter were taking antidepressantand antipsychotic medications and had ahistory of psychiatric hospitalisation, as wellas a history of illicit intravenous drug use. Inaddition, BZD users scored notably higher onHamilton’s Rating Scale for Anxiety (HAM-A)and Zung’s Self-Rating Depression Scale (SDS)than non- BZD users. A history of psychiatrichospitalization, illicit drug use, unemploy-ment, symptoms of anxiety, and a positive testfor hepatitis C (antibodies to the hepatitisvirus) were independently associated withBZD use in this prison, according to multi-variate logistic regression analysis.

In Germany, Last (1979) found that amongprisoners older than 50 years, physical dis-eases, in particular cardiovascular disorders,cause sleep disturbances in 19% of the detai-nees. Five per cent of sleep problems were dueto an abuse of coffee or nicotine and theremaining sleep complaints were due to emo-tional disturbances in the broadest sense.

Management and efficiency of insomniatreatment in detention

In Germany, physicians were convinced thatthe usual medical treatment for simple insom-nia was not successful in a prison setting (Last,1979). According to the author of this study,the prisoners ‘abused the normally used

medicaments to get into a state of ecstasy.’Therefore, in the German prison, herbalmedications (‘with a vegetable basis’), neuro-leptics and antidepressants were the preferredtreatments.

In the Geneva remand prison, two studiesexamined the management and efficiency ofinsomnia treatment (Elger, 2003; Elger,2004b). In the first study, the severity andduration of insomnia in detention were ana-lysed by measuring sleep quality and itsdifferent components using the PittsburghSleep Quality Index (Buysse et al., 1989). Thisinstrument was chosen because the PSQI isknown to provide a reliable, valid and stan-dardised measure of sleep quality, to discrimi-nate between ‘good’ and ‘poor’ sleepers and topermit a brief, clinically useful assessment of avariety of sleep disturbances that might affectsleep quality. The 19-item self-rating ques-tionnaire yields a global score between 0 and21. A global score >5 is considered to be anindicator of relevant sleep disturbances. Itconsists of seven components: sleep quality,sleep latency, sleep duration, sleep efficiency,sleep disturbances, sleep medication, and daydysfunction (the latter being defined as troublestaying awake while eating meals, watchingtelevision or engaging in social activity).

The total PSQI scores found in the remandprison among 52 randomly chosen patientscomplaining of insomnia were 12.3+/- 4.7.These scores were similar to, or worse than,those of patients with primary insomnia(Backhaus et al., 2002), long term hypnoticdrug users (Morgan et al., 2003), end stagerenal disease patients or HIV patients whocomplain of sleep disturbances (Tsay andChen, 2003; Dreher, 2003). In the Swissremand prison (Elger, 2003), follow-up of 40patients after ten days and 16 patients aftertwo months showed significant improvements.Nevertheless, it has to be noted that PSQIscores stayed at high levels (10.6 after ten daysand 9.6 after two months). The study did notfind any differences in patients’ GHQ (generalhealth questionnaire) scores and conditions ofimprisonment after ten days or two months ascompared with the first time point at which thePSQI was administered. However, the study

6 Med. Sci. Law (2007) Vol. 47, No. 3


suggested factors to which changes could beattributed. ‘Stressful events’ were reported by74% of insomniac prisoners when they werefirst evaluated by the PSQI, but only by 54% ofinsomniac prisoners after ten days. In addi-tion, an increased medication intake after tendays was observed. After two months, adecrease in the number of room-mates from amean of 2.8 to 2.1 was noted that could haveinfluenced sleep quality. After ten days andafter two months more than 90% of the re-evaluated patients took hypnotics. It might bereassuring that no medication increaseoccurred between ten days and two monthsand that sleep quality was stable (scores 10.6and 9.6). However, this also means that theprisoners included in the study manifested achronic requirement of hypnotics in spite ofefforts of their physicians to include non-pharmacological measures: in this study sleephygiene information was distributed duringthe consultations.

In another study in the same prison (Elger,2004b) the clinical management of insomniacomplaints in non-substance-misusing prison-ers was examined in order to judge the qualityof medical consultation and the effectiveness ofdrug prescription. This study was done retro-spectively and included the medical records of112 non-substance-misusing prisoners com-plaining of insomnia at medical consultationover a one-year period. Aspects examined werethe documentation of the history of theinsomnia complaint, the documentation of theclinical evaluation and of the type, durationand effectiveness of treatment. Findings in-cluded a prescription of hypnotics to 111patients (80% benzodiazepines or Zolpidem)and a limited documented insomnia work-up:information from the history about sleephabits, sleep latency and previous hypnoticuse had been noted for less than a third of thepatients, and information about the impact ofinsomnia, such as fatigue, on daily activity inonly 7%. In more than 60% of the patients,insomnia complaints persisted for more thanthree weeks. In 37% patients, improvementwas complete (defined subjectively based onpatients’ complaints), in 18% it was absent,and in 30% it was incomplete while taking the

prescribed hypnotics. Patients with or withoutonly partial improvement of insomnia receivedthe highest number of hypnotics (mean 2.4,versus 1.4 for patients with total improvement,95% CI of the difference: 0.71.4). It wasconcluded from this study that correctionalhealth care physicians’ evaluation for insom-nia was incomplete, although similar to stu-dies involving ‘normal’ US physicians workingoutside correctional facilities.

Drug prescription in the prison did not seemto have been effective in completely relievinginsomnia complaints in a sizeable number ofpatients.

SUMMARY AND CONCLUSIONS FROM ALLSTUDIES IN DETENTION

Insomnia complaints are frequent. Up to 40%of prisoner patients in a general medicineoutpatient service seek medical consultationfor sleep problems. Insomnia in places ofdetention cannot be reduced to a secondaryproblem related to substance abuse andmental illness, but appears to be an indepen-dent situational problem. Correctional healthcare physicians’ evaluation of insomnia isinsufficient. Drug prescription works well insome patients, but has a limited effect incompletely relieving insomnia in others.Several major conclusions arise. First, a clearneed seems to exist for the education of prisonhealth care professionals on insomnia evalua-tion and management. Second, additional non-pharmacological treatment in the prisonhealth care setting should be used morefrequently. Third, prison health care servicesshould develop clear guidelines for theirpersonnel that are based on research evidenceabout insomnia. These guidelines should con-tain the general recommendation to takeinsomnia complaints seriously and they shouldaddress the recommended diagnostic steps andmanagement recommendations, includingnon-pharmacological treatment.

Treatment recommendations should bebased on the principle of equivalence andshould not deprive prisoners of medicationthat is used for non-detained patients. Noevidence exists so far that the prescription ofBZD hypnotics should be replaced in general in



prisons by neuroleptics or antidepressants.Most neuroleptics have serious side effects,as have certain classes of antidepressants. Ifguidelines in places of detention differ fromthose used outside the prison setting, theconsequences of the treatment practice shouldbe strictly monitored before and after anychanges.

Fourth, more studies in correctional facil-ities are needed to evaluate different treat-ment strategies. What is the feasibility ofnon-pharmacological treatment in prison?What are the outcomes of non-pharmaco-logical treatment as compared with pharma-cological treatment? Do guidelines changepractice? What is the compliance with guide-lines by clinicians? What is the effect ofdifferent treatment strategies on violence,suicide, and the severity of complaints, aswell as on clinically observed symptoms?Ideally, the studies should be conducted inparallel in different prison types and indifferent countries.

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article · 2013-07-16 · scribed psychotropic drugs were benzodiaze-pines and sedative...

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