Sleep Inequities Persist in Various Prisons, Hospitals, Universities

The last day of the SLEEP 2024 Annual Meeting was June 5, which started with a symposium on deserts in sleep coverage. Inequities in sleep duration, diagnosis of sleep conditions, and treatment of those conditions persist in various locations throughout the nation, including prisons, hospitals, and universities.

Sleep in Incarcerated Individuals

The prevalence and effect of sleep dysfunction in prisons was the focus of the first presentation, conducted by Lauren Robinson, MD, MPH, an adjunct assistant professor of forensic psychiatry at the Northwestern Feinberg School of Medicine. Diagnosis and treating this sleep dysfunction presents several challenges, however.

“[The US] is 1 of the top incarcerators in the world as a percentage of our population,” said Robinson. “We have 1.9 million Americans within the correctional system currently.” This number, she said, has gone down by 26% since 2012 but has risen by 2% since 2021, according to the Bureau of Justice Statistics.¹ Black men are especially victim of incarceration, with a rate 6 times higher than that of White men on average, making up 34% of the prison population.

From the same report by the Bureau of Justice Statistics, mental health issues are at a higher prevalence in people who are incarcerated. “There’s a reason that prisons and jails have been called the largest mental health facilities in the United States,” said Robinson. “It’s because there is a huge proportion of those who are incarcerated [that] have some type of mental illness.”

According to the report, 43% of state prisoners had a history of mental illness, of which 49% had a history of substance use disorder, 27.1% had major depression, 23.3% had bipolar disorder, and 14.1% had posttraumatic stress disorder.

Sleep dysfunction can exacerbate these mental health problems. However, the prevalence of sleep dysfunction in prisons is harder to ascertain. Prevalence ranges can span from 26.2% to 72.5% when looking into sleep dysfunction.² “This wide variability is due to just the general variations in different prison conditions. Some prisons are run differently than others are [and] they use different assessment tools,” explained Robinson.

Women were also more likely to have sleep dysfunction compared with men who were also incarcerated. Insomnia was also more likely to occur after detainment, with 50% reporting insomnia before arrest compared with 79% after.³ Reasons for this, according to Robinson, could be a variety of things. There is minimal time with lights off, poor temperature regulation, noise, inconsistent light exposure, poor quality mattresses, and the general stress of being in prison.

There are also several risk factors for sleep dysfunction in prisons. “Studies have shown that any type of a mental health diagnosis can predispose you to something like [sleep dysfunction], and this would include substance use disorders while you’re incarcerated,” said Robinson.

Other risk factors include borderline personality disorder and being a victim of bullying prison. Referral burden is also a challenge in treating incarcerated people, as 1 in 10 intakes have requested psychological services for insomnia.⁴ Without treatment, poor sleep can lead to depression, anxiety, suicidality, and aggression.

Robinson pointed out that a lack of medical professionals in this area is the biggest challenge in in treating and diagnosing sleep dysfunction in prisons. “We just have a dearth of people who are willing to work in this setting. We don’t have enough doctors, we don’t have enough mental health workers, we don’t have enough social workers who are actually working in the system,” she said. “There’s just a huge strain in the system for any type of professional help for insomnia.”

Other challenges include a lack of prioritizing insomnia in these patients, restrictions on medicine, limited access to medical devices, and poor quality of research in this population. This lack of quality can be due to a lot of things, said Robinson, including inconsistent use of assessment tools, no uniform definition of sleep dysfunction, and difficulty obtaining approval of the incarcerated to use as research subjects.

“Part of this is for a reason. There have been abhorrent research studies that have been forced upon those who have been incarcerated against their wills…And so there have been protections set forth, and that’s a good thing. But in some way it really prohibits us from doing most of the research we want to do in those settings,” she said.

Robinson recommended some interventions and treatment approaches that could help in addressing incarcerated people who have sleep dysfunction. This would include screening on intake and keeping up with an individual’s sleep hygiene. She also recommended medications but noted that a lot of them are not approved for use in corrections facilities.

“Things like meditation techniques have actually been shown to really help [and] it’s a low-cost way to intervene,” said Robinson. Other items like earplugs, eye masks, and improved bedding could be a way to improve sleep in this population. Lastly, advocacy and policy changes can help to encourage these changes as well as reduce suicide risk in the prison population and get a uniform sleep schedule for individuals in correctional facilities.

“Addressing sleep dysfunction in prisons is crucial for improving prison management, reducing risks of violence and suicide, allocating funds, and to ensure the dignity and well-being of the incarcerated, which is a vulnerable and underserved population,” Robinson concluded.

Hospital | Image credit: Spiroview Inc. - stock.adobe.com

Sleep Dysfunction in Universities and Hospitals

Ronald Gavidia Romero, MD, MS, an assistant professor of neurology at the University of Michigan, conducted his own presentation about sleep dysfunction in other populations, namely in young adults who are attending college and people who work in hospitals. This also consisted of students studying health care, either as a doctor or a nurse.

Sleep for college students is especially important for continuing development and to maintain their well-being. However, up to 65% of college students could face difficulties in obtaining proper sleep, with the most common sleep disturbances or disorders being insufficient sleep, insomnia, circadian rhythm disorders, and sleep apnea.

“As recommended by the National Sleep Foundation, college students should be getting at least 7 to 9 hours of sleep, but that’s not happening all the time,” said Romero. “And actually, about 70% of this population has failed to report at least 7 hours of sleep. So that’s a huge problem.”

Reasons for the lack of sleep include academic pressure, employment, and extracurricular activities, said Romero. Short sleep duration could lead to poor academic performances, mood disorders, and excessive daytime sleepiness. Insomnia is also prevalent in approximately 20% of college students due to anxiety, stress, poor sleep hygiene, or socioeconomic status. These sleep conditions can be addressed through sleep education, cognitive behavioral strategies, and the adjustment of school schedules.

Circadian rhythms can also be affected in college students. “It is particularly important to spot in college students because during the transition between adolescence into adulthood, there is a biological change that leads them to become more like night owls, and then that disrupts their circadian rhythm,” said Romero. This disruption could be associated with cardiometabolic health, mental health, and other risk behaviors.

“Some interventions that have been reported to be helpful in this population include work on behaviors, work on the habits, and perhaps the use of light therapy,” said Romero.

Sleep in the hospital setting operates a little differently. The hospital setting could determine the outcomes of sleep due to the environmental, disease-related, and psychological aspects of the setting. Both patients and workers have described impaired sleep.

Health care workers have been affected by poor sleep, especially those who work in the night shift. Sedentarism, high stress, and shift work were all factors in poor sleep. In particular, night shift nurses report 6.4 to 6.6 hours of sleep and 40% to 80% report poor sleep quality. Nurses with a BSN degree or higher appear to have the worst effects, said Romero. Physicians in training also report similar short sleep duration of 6.2 hours, with their sleep deprivation potentially affecting attention, cognition, motor skills, and patient safety. Similarly to college students, up to 50% to 60% of health care students reported short sleep of less than 7 hours, with 33% reporting a duration of 5 to 7 hours.

Romero emphasized sleep education for these groups with cognitive therapy, as this could help individuals understand the consequences of not getting enough sleep, especially when it comes to doctors or nurses making decisions that could affect a patient’s life. Romero noted that a reduction in work hours for health care workers in hospitals was introduced to help with sleep deprivation, but other shift adjustments can be made to more effectively reduce these sleep deprivations.

Hospitalized patients also encounter sleep disruptions, with up to 76% reporting sleep difficulties while in the hospital across all ages. The most extreme example is in hospitalized adults who report a reduction of 83 minutes in average sleep duration.

“Why are we even talking about the sleeping people who are going to be at the hospital just for a few days? The problem is that, that stay at the hospital, we trigger some behaviors that persist at home…So that’s why it’s very important,” said Romero.

Mindfulness techniques, environmental modifications, relaxation, and sleep hygiene can all help in reducing sleep disturbances in hospitalized patients of all ages. Environmental modifications could include adjusting the lights and the presenting of different measures, said Romero.

“Behavioral interventions may help with this, schedule regulation seems to play a significant role here, but it seems we will have to work on policies and different things to support a systemic approach,” concluded Romero.

Sleep deprivation is persistent in all parts of life. Whether an individual is incarcerated, in college, or in the hospital, sleep deprivation can affect them all and lead to adverse events, not limited to mental health disorders and affect concentration and academic performance. Interventions, policy changes, and education are 3 steps that can be taken to address sleep deprivation in these groups.

References

1. Federal prisoner statistics collected under the First Step Act, 2023. Bureau of Justice Statistics. Published November 2023. Accessed June 5, 2024. https://bjs.ojp.gov/library/publications/federal-prisoner-statistics-collected-under-first-step-act-2023
2. Sheppard N, Hogan L. Prevalence of insomnia and poor sleep quality in the prison population: a systematic review. J Sleep Res. 2022;31(6):e13677. doi:10.1111/jsr.13677
3. Ireland JL, Culpin V. The relationship between sleeping problems and aggression, anger, and impulsivity in a population of juvenile and young offenders. J Adolesc Health. 2006;38(6):649-655. doi:10.1016/j.jadohealth.2005.05.027
4. Diamond PM, Magaletta PR, Harzke AJ, Baxter J. Who requests psychological services upon admission to prison? Psychol Serv. 2008;5(2):97-107. doi:10.1037/1541-1559.5.2.97