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PMC Articles

“What if that’s your last sleep?” A qualitative exploration of the trauma of incarceration and sleep

PMCID: PMC10838125

PMID: 38314119

Abstract

Abstract Study Background/Objectives Sleep is an underexplored factor in the health of people involved in the criminal legal system. This study addresses the paucity of research on how individual, social, and physical environmental factors impact sleep health during and after incarceration by highlighting the voices of people involved in the criminal legal system through a community-engaged qualitative research approach. Methods We conducted 20 semi-structured interviews with men recently released from prison for a study on trauma and healthcare during incarceration and after release. Interviews were coded and analyzed using reflexive thematic analysis and a critical realist framework. Our research team included people with a history of incarceration who performed central roles in the research process. Results Three themes emerged from participants’ descriptions of sleep during and after incarceration: (1) concerns about health contributing to sleep problems, (2) lack of access to treatment for sleep disorders leading to ongoing sleep problems, and (3) issues of safety contributing to sleep problems during incarceration and after release. Conclusions This study identifies factors and domains influencing sleep during and after incarceration. By identifying which interpersonal, environmental, and structural factors impact sleep quality, medical and carceral staff are better equipped to ameliorate sleep health disparities within populations with a history of incarceration and those actively bound by the criminal legal system. Future research should examine other factors impacting sleep in incarcerated and recently released populations and develop multi-level interventions to improve sleep health.

Full Text

Constituting almost one-third of our lives, sleep is essential for human survival [1]. This routine altered state of consciousness serves a number of important health functions from memory consolidation to maintaining overall health and wellbeing [2]. Poor sleep health is marked by deficiencies in quantity and/or quality of sleep, resulting in suboptimal health [3]. Varying levels and manifestations of poor or deficient sleep (insomnia, parasomnia, insufficient sleep duration, sleep apnea, etc.) affect 50–70 million people in the United States, with disproportionate morbidity in low-income and racial and ethnic minoritized populations. The causes of poor sleep health are multifactorial and multi-level, spanning mental health conditions (e.g. depression, post-traumatic stress disorder) to social and physical characteristics of the sleep environment [4–7].
Neighborhoods characterized by greater social disorder, lower social cohesion, and lower safety are associated with shorter sleep duration, even after controlling for resident socioeconomic status and physical environment [8–11]. A study on social patterning of sleep in African Americans by Johnson et al. showed low education and low income’s association with long sleep (>9 h) and poorer sleep quality, and high neighborhood violence’s association with shorter and poorer quality sleep [12]. Conversely, positive aspects of the physical neighborhood environment, such as lower ambient noise levels, are associated with improved sleep [13, 14]. Similarly, self-reported neighborhood safety has been associated with lower daytime sleepiness [15]. A recent review showed promising improvements in sleep health by addressing environmental characteristics [7], and emerging research identified sleep environment as an important modifiable mediator between poor sleep and cardiovascular disease risk factor (hypertension, diabetes, obesity) management [5]. If your “neighborhood” is a carceral facility, your sleep may be suboptimal. Incarceration, however, is a virtually unexplored factor contributing to poor sleep health despite its prevalence in the United States and its disproportionate impact on minoritized populations.
Over two million people are incarcerated in the United States, and an estimated 11 million individuals cycle through jails and prisons yearly [16–18]. Minoritized groups are disproportionately incarcerated with Black people incarcerated at five times and Hispanic people at 2.5 times the rate of White people [19]. Incarcerated people may have unique individual-level reasons for poor sleep health. For instance, incarcerated people globally have higher rates of mood disorders and chronic pain, which amplify poor sleep, compared with those who have never been incarcerated [20–22]. Carceral systems’ social and physical environment may also impact sleep. Exposure to violence and stressful interpersonal relationships between incarcerated people and with staff are associated with increased psychosocial stress and sleep problems (e.g. nightmares, insomnia) [3, 7, 10, 23, 24]. Environmental factors like noise, light, air quality, and extreme temperatures similarly contribute to poor sleep [25–29]. Restrictive policies around sleep/wake schedules, lockdowns, and overcrowding in carceral facilities compound these negative impacts [25, 26, 30]. Carceral systems often use sleep deprivation as a form of control through “health checks” (read: constant forced waking), 2 am med calls, and night-shift work [4, 30, 31]. In our clinical, research, and lived experience, extant sleep issues are further exacerbated by an overt lack of access to assessment for sleep problems, over-the-counter sleep aids (e.g. melatonin), and standard sleep treatments (e.g. prescription sleep medication, CBT-I). In response to sleep complaints, carceral medical staff often prescribe sedative psychiatric medication. Incarcerated people may take matters into their own hands and use illicit drugs as sleep aids. For others, sleep problems go untreated. Assuming they are even able to acquire healthcare after release, people are often unable to get prescriptions for the medications they received while incarcerated because providers think the medications prescribed are no longer appropriate.
Following release, sleep environments may be unstable or remain under supervision of the criminal legal system. People returning to the community live in various settings (e.g. with family/friends, in shelters or halfway houses). For some, moving from a highly regimented and controlled environment to one with little structure can prove challenging. Others experience the move to congregate housing, shelters, or halfway houses as a continuation of the carceral environment, still governed by restrictions on when one can eat, work, sleep, what medications one can receive for sleep disorders, and contentious interactions with staff and roommates. In both cases, those returning to the community often live in low socioeconomic status neighborhoods, a predictor of waking after sleep onset [23].
Despite the increased risk for poor sleep health during incarceration and following release, there has been limited research conducted in the United States on the sleep implications of incarceration and almost none that focuses on minoritized populations [32, 33]. Past studies are primarily quantitative and focused on insomnia in carceral settings with inconsistent results, varying from 11% to 81% morbidity [27, 32, 34–41]. While a number of studies describe light, noise and exposure to violence in their background sections as environmental factors that potentially influence sleep, no studies have provided comprehensive description of sleep environments experienced by incarcerated people or those just released [38, 42–44]. The current study centers the voices and lived experiences of incarcerated persons’ to understand how individual, social, and physical environmental factors contribute to sleep problems during incarceration and after release.
We conducted and analyzed 20 semi-structured qualitative interviews with men recently released from a carceral facility focused on healthcare experiences and trauma during incarceration [45]. The interview guide was designed, tested, and revised with input from the study PI, staff with a history of incarceration, and medical students. While sleep was not explicitly asked about, it nonetheless emerged as a significant motif in our original coding. The current analysis focuses on that emergent sleep theme. We extracted all sections of interviews in Dedoose (a qualitative data management software) coded for sleep and conducted thematic analysis using an inductive/descriptive approach and critical realist framework. This approach ensured that the analysis was focused on the voices of the participants and how they thought and felt about sleep [46–51].
This study was approved by the Yale University Institutional Review Board. We report our study results using the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines for qualitative research [52]. Additional information on the original study methodology is detailed in the initial publication of results [45].
We used an inductive and descriptive approach to reflexive thematic analysis and a critical realist framework to center the voices of the men we interviewed and their perspectives on the carceral experience [46–50, 53]. This approach employed an empathetic interpretation of participants’ subjective perspectives on the carceral experience, requiring the researcher to interpret the interviews from the participant’s perspective and consider the social and cultural context in prison and after release [46–51, 53]. Our analysis team included the study PI, a medical student, and a student intern and research assistant, both with a history of incarceration. Additional input on the analysis was also provided (phases 5 and 6) by the two MDs with expertise in incarceration and health and sleep medicine. Table 1 shows the steps in the analysis process and which team members were involved in each step.
The design, implementation, and data analysis of this project were informed by the authors’ lived experience of incarceration and their experience in providing medical care and conducting research about people with a history of incarceration. We aimed to have people from diverse backgrounds and perspectives at each stage of the research to ensure that we were considering a variety of factors and not including only one viewpoint in the study. Past research has shown that without the input and leadership of people directly impacted by incarceration, interventions are not adopted by correctional and healthcare systems, utilized by patients, or disseminated to scale [54, 55].
Study participants spent an average of 11 years in prison and were incarcerated 6.4 times. Participants included Black (40%), White (20%), and Hispanic and Latino (40%) men with a mean age of 46 (range, 23–58 years). Almost all participants (95%) had spent time in solitary confinement (meaning they were isolated from other incarcerated people and staff and spent 23 hours a day alone in a small cell), ranging from 14 days to 15 years. Almost half of the participants (45%) had been diagnosed with post-traumatic stress disorder. Table 2 describes the demographics of the study sample.

You get scared, I’m not going lie. You really do get scared because you never know if one day you might go through something that’s life-threatening and they have no solution for you. So, it’s like now your down at medical and you’re feeling like you’re damn near on your deathbed, and it’s like, the only thing they can tell you is, “Oh you’ll be all right, here’s some Motrin.” Or, “You’ll be all right, just sleep it off and come see us tomorrow.” So now it’s like, what if you do go back, and that’s your last sleep? (Melvin)
The concerns expressed by both participants highlights an apprehension that all of the men expressed around worries about health and the distress that they caused. Our earlier work from this study [45], describes in detail the trauma the men experienced as a result of the healthcare they received in these carceral facilities. Illness and pain from health problems or injuries were routinely brought up by the men interviewed. In carceral settings, concerns about trust and privacy may additionally prevent people from seeking care and contribute to sleep problems.
Our results identify some ways the treatment of health conditions in carceral facilities can contribute to sleep problems and our earlier paper from these interviews highlights healthcare-induced trauma in carceral facilities [45]. A previous study of insomnia in incarcerated people found that those with insomnia were more likely to have a concurrent medical or mental health condition [56]. Concerns about health and the paucity of treatment options during incarceration, not just the health conditions themselves, contributed to insomnia and should be investigated in future studies.
Few studies on sleep and incarceration have focused on what assessments, treatments, and interventions for sleep problems are available for this population. Medications commonly used to treat sleep in carceral settings include over-the-counter remedies like Benadryl or allergy medications and psychotropic medications like Remeron (anti-depressant) and Seroquel (antipsychotic) [43]. These medications may be used in lieu of insomnia medications used in community settings (e.g. Ambien, Lunesta, Belsomra) because the common causes of lack of sleep in carceral settings (anxiety, trauma, fear of violence) may be viewed as needing a stronger sedative to counteract. The use of these medications during incarceration may help sleep in the short term, but cause problems after release. Participants reported that they were often unable to get these medications from their primary care provider in the community, contributing to worse sleep after release. Noted by participants in this study and in our clinical, research, and lived experience, lack of access to sleep medication and CBT-I—options that are readily available to people outside the carceral system—exacerbates sleep problems, leading to mood changes that negatively moderate interactions with cellmates, other incarcerated people, and facility staff. Given the interconnected nature of trauma and trauma-related sleep problems, integrating CBT-I with PTSD treatment may improve the efficacy of sleep-related care in this population. Access to formal assessment and treatment for sleep disorders and comorbid mental health conditions during incarceration and after release could improve sleep health and reduce exacerbation and development of other health problems, improving mental health and social climate in facilities.
One study explored the use of interventions like mindfulness to improve well-being, using sleep as a secondary outcome, finding mindfulness-based emotional intelligence interventions decreased anxiety and depression and significantly improved sleep quality scores on the Pittsburgh Sleep Quality Index (PSQI) following intervention [42]. While CBT-I is commonly used to treat insomnia in community settings, it is not a treatment available in carceral settings despite its proven efficacy in this population. A study by Randall et al. [32] showed promising results using a one-shot CBT-I intervention to treat insomnia in incarcerated men, showing a reduction in the severity of insomnia and a reduction in depression and anxiety. A better understanding of the variety of sleep problems faced by incarcerated people and the factors contributing to sleep disparities in this population will aid in the adaptation and development of more population-specific interventions. Furthermore, a bolstered preventative care structure in carceral settings can reduce urgent care load and proactively improve sleep health.
Rumination and nightmares were barriers to sleep, triggered by fear of violence in the carceral social environment. In carceral facilities, noise and violence often go together, with noise signaling events that could be disturbing to witness or directly experience. Even requesting others to be quieter can incite violence. One must choose between sleep and surviving the night. These coping tactics create a positive feedback loop in which sleep deprivation due to fear of violence propagates more violence. Lack of sleep has been shown to increase sensitivity to even minor events, resulting in inappropriately volatile retaliations [57].
While here we focused primarily on how healthcare and trauma impact sleep, some participants did mention how factors in the physical environment can contribute to sleep problems. Adornetti et al. [58] highlight the impact of light and facility schedules on the sleep of juveniles in detention: issues in both juvenile and adult facilities that could be addressed to improve sleep. A recent review indicated the promise of addressing environmental characteristics to improve sleep, and emerging research identified sleep environment as an important modifiable mediator between sleep deficiency and worsening management of cardiovascular disease risk factors, including hypertension, diabetes, and obesity [5, 7]. Future studies should also examine how the physical environment in correctional facilities can affect sleep health.
While past research has pointed to noise, light, facility elements, and sleeping conditions as potential causes of sleep problems in this population [25–27, 31, 59], no studies have examined sleep after release from prison. The possible mechanisms of poor sleep health during incarceration and after release should be explored in future work to better understand and mitigate racial disparities in sleep health.
Although sleep is considered a basic need, it is rarely considered in research or programs focused on those impacted by the criminal legal system [60]. We identified new domains that may influence the sleep health of the millions of people with a history of incarceration. This work informs new understandings of how we must address sleep health disparities. Future work should focus on exploring sleep health more broadly among incarcerated people by conducting additional qualitative studies focused on sleep health in this population, studies to adapt existing sleep instruments to better assess sleep in this population, and larger studies that employ subjective and objective measures of sleep both during incarceration and after release. Explorations of sleep during incarceration focused on adapting and testing interventions for sleep and considering multi-level interventions that address sleep at the individual and carceral facility level (e.g. schedule, noise, light) are critical next steps in better understanding and addressing sleep in this population.

Sections

"[{\"pmc\": \"PMC10838125\", \"pmid\": \"38314119\", \"reference_ids\": [\"CIT0001\", \"CIT0002\", \"CIT0003\", \"CIT0004\"], \"section\": \"Background\", \"text\": \"Constituting almost one-third of our lives, sleep is essential for human survival [1]. This routine altered state of consciousness serves a number of important health functions from memory consolidation to maintaining overall health and wellbeing [2]. Poor sleep health is marked by deficiencies in quantity and/or quality of sleep, resulting in suboptimal health [3]. Varying levels and manifestations of poor or deficient sleep (insomnia, parasomnia, insufficient sleep duration, sleep apnea, etc.) affect 50\\u201370 million people in the United States, with disproportionate morbidity in low-income and racial and ethnic minoritized populations. The causes of poor sleep health are multifactorial and multi-level, spanning mental health conditions (e.g. depression, post-traumatic stress disorder) to social and physical characteristics of the sleep environment [4\\u20137].\"}, {\"pmc\": \"PMC10838125\", \"pmid\": \"38314119\", \"reference_ids\": [\"CIT0008\", \"CIT0012\", \"CIT0013\", \"CIT0014\", \"CIT0015\", \"CIT0007\", \"CIT0005\"], \"section\": \"Background\", \"text\": \"Neighborhoods characterized by greater social disorder, lower social cohesion, and lower safety are associated with shorter sleep duration, even after controlling for resident socioeconomic status and physical environment [8\\u201311]. A study on social patterning of sleep in African Americans by Johnson et al. showed low education and low income\\u2019s association with long sleep (>9\\u00a0h) and poorer sleep quality, and high neighborhood violence\\u2019s association with shorter and poorer quality sleep [12]. Conversely, positive aspects of the physical neighborhood environment, such as lower ambient noise levels, are associated with improved sleep [13, 14]. Similarly, self-reported neighborhood safety has been associated with lower daytime sleepiness [15]. A recent review showed promising improvements in sleep health by addressing environmental characteristics [7], and emerging research identified sleep environment as an important modifiable mediator between poor sleep and cardiovascular disease risk factor (hypertension, diabetes, obesity) management [5]. If your \\u201cneighborhood\\u201d is a carceral facility, your sleep may be suboptimal. Incarceration, however, is a virtually unexplored factor contributing to poor sleep health despite its prevalence in the United States and its disproportionate impact on minoritized populations.\"}, {\"pmc\": \"PMC10838125\", \"pmid\": \"38314119\", \"reference_ids\": [\"CIT0016\", \"CIT0019\", \"CIT0020\", \"CIT0003\", \"CIT0007\", \"CIT0010\", \"CIT0023\", \"CIT0024\", \"CIT0025\", \"CIT0025\", \"CIT0026\", \"CIT0030\", \"CIT0004\", \"CIT0030\", \"CIT0031\"], \"section\": \"Background\", \"text\": \"Over two million people are incarcerated in the United States, and an estimated 11 million individuals cycle through jails and prisons yearly [16\\u201318]. Minoritized groups are disproportionately incarcerated with Black people incarcerated at five times and Hispanic people at 2.5 times the rate of White people [19]. Incarcerated people may have unique individual-level reasons for poor sleep health. For instance, incarcerated people globally have higher rates of mood disorders and chronic pain, which amplify poor sleep, compared with those who have never been incarcerated [20\\u201322]. Carceral systems\\u2019 social and physical environment may also impact sleep. Exposure to violence and stressful interpersonal relationships between incarcerated people and with staff are associated with increased psychosocial stress and sleep problems (e.g. nightmares, insomnia) [3, 7, 10, 23, 24]. Environmental factors like noise, light, air quality, and extreme temperatures similarly contribute to poor sleep [25\\u201329]. Restrictive policies around sleep/wake schedules, lockdowns, and overcrowding in carceral facilities compound these negative impacts [25, 26, 30]. Carceral systems often use sleep deprivation as a form of control through \\u201chealth checks\\u201d (read: constant forced waking), 2 am med calls, and night-shift work [4, 30, 31]. In our clinical, research, and lived experience, extant sleep issues are further exacerbated by an overt lack of access to assessment for sleep problems, over-the-counter sleep aids (e.g. melatonin), and standard sleep treatments (e.g. prescription sleep medication, CBT-I). In response to sleep complaints, carceral medical staff often prescribe sedative psychiatric medication. Incarcerated people may take matters into their own hands and use illicit drugs as sleep aids. For others, sleep problems go untreated. Assuming they are even able to acquire healthcare after release, people are often unable to get prescriptions for the medications they received while incarcerated because providers think the medications prescribed are no longer appropriate.\"}, {\"pmc\": \"PMC10838125\", \"pmid\": \"38314119\", \"reference_ids\": [\"CIT0023\"], \"section\": \"Background\", \"text\": \"Following release, sleep environments may be unstable or remain under supervision of the criminal legal system. People returning to the community live in various settings (e.g. with family/friends, in shelters or halfway houses). For some, moving from a highly regimented and controlled environment to one with little structure can prove challenging. Others experience the move to congregate housing, shelters, or halfway houses as a continuation of the carceral environment, still governed by restrictions on when one can eat, work, sleep, what medications one can receive for sleep disorders, and contentious interactions with staff and roommates. In both cases, those returning to the community often live in low socioeconomic status neighborhoods, a predictor of waking after sleep onset [23].\"}, {\"pmc\": \"PMC10838125\", \"pmid\": \"38314119\", \"reference_ids\": [\"CIT0032\", \"CIT0033\", \"CIT0027\", \"CIT0032\", \"CIT0034\", \"CIT0038\", \"CIT0042\"], \"section\": \"Background\", \"text\": \"Despite the increased risk for poor sleep health during incarceration and following release, there has been limited research conducted in the United States on the sleep implications of incarceration and almost none that focuses on minoritized populations [32, 33]. Past studies are primarily quantitative and focused on insomnia in carceral settings with inconsistent results, varying from 11% to 81% morbidity [27, 32, 34\\u201341]. While a number of studies describe light, noise and exposure to violence in their background sections as environmental factors that potentially influence sleep, no studies have provided comprehensive description of sleep environments experienced by incarcerated people or those just released [38, 42\\u201344]. The current study centers the voices and lived experiences of incarcerated persons\\u2019 to understand how individual, social, and physical environmental factors contribute to sleep problems during incarceration and after release.\"}, {\"pmc\": \"PMC10838125\", \"pmid\": \"38314119\", \"reference_ids\": [\"CIT0045\", \"CIT0046\"], \"section\": \"Study Overview\", \"text\": \"We conducted and analyzed 20 semi-structured qualitative interviews with men recently released from a carceral facility focused on healthcare experiences and trauma during incarceration [45]. The interview guide was designed, tested, and revised with input from the study PI, staff with a history of incarceration, and medical students. While sleep was not explicitly asked about, it nonetheless emerged as a significant motif in our original coding. The current analysis focuses on that emergent sleep theme. We extracted all sections of interviews in Dedoose (a qualitative data management software) coded for sleep and conducted thematic analysis using an inductive/descriptive approach and critical realist framework. This approach ensured that the analysis was focused on the voices of the participants and how they thought and felt about sleep [46\\u201351].\"}, {\"pmc\": \"PMC10838125\", \"pmid\": \"38314119\", \"reference_ids\": [\"CIT0052\", \"CIT0045\"], \"section\": \"Study Overview\", \"text\": \"This study was approved by the Yale University Institutional Review Board. We report our study results using the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines for qualitative research [52]. Additional information on the original study methodology is detailed in the initial publication of results [45].\"}, {\"pmc\": \"PMC10838125\", \"pmid\": \"38314119\", \"reference_ids\": [\"CIT0046\", \"CIT0053\", \"CIT0046\", \"CIT0053\", \"T1\"], \"section\": \"Data analysis\", \"text\": \"We used an inductive and descriptive approach to reflexive thematic analysis and a critical realist framework to center the voices of the men we interviewed and their perspectives on the carceral experience [46\\u201350, 53]. This approach employed an empathetic interpretation of participants\\u2019 subjective perspectives on the carceral experience, requiring the researcher to interpret the interviews from the participant\\u2019s perspective and consider the social and cultural context in prison and after release [46\\u201351, 53]. Our analysis team included the study PI, a medical student, and a student intern and research assistant, both with a history of incarceration. Additional input on the analysis was also provided (phases 5 and 6) by the two MDs with expertise in incarceration and health and sleep medicine. Table 1 shows the steps in the analysis process and which team members were involved in each step.\"}, {\"pmc\": \"PMC10838125\", \"pmid\": \"38314119\", \"reference_ids\": [\"CIT0054\", \"CIT0055\"], \"section\": \"Engaging people with a history of incarceration in research\", \"text\": \"The design, implementation, and data analysis of this project were informed by the authors\\u2019 lived experience of incarceration and their experience in providing medical care and conducting research about people with a history of incarceration. We aimed to have people from diverse backgrounds and perspectives at each stage of the research to ensure that we were considering a variety of factors and not including only one viewpoint in the study. Past research has shown that without the input and leadership of people directly impacted by incarceration, interventions are not adopted by correctional and healthcare systems, utilized by patients, or disseminated to scale [54, 55].\"}, {\"pmc\": \"PMC10838125\", \"pmid\": \"38314119\", \"reference_ids\": [\"T2\"], \"section\": \"Results\", \"text\": \"Study participants spent an average of 11 years in prison and were incarcerated 6.4 times. Participants included Black (40%), White (20%), and Hispanic and Latino (40%) men with a mean age of 46 (range, 23\\u201358 years). Almost all participants (95%) had spent time in solitary confinement (meaning they were isolated from other incarcerated people and staff and spent 23 hours a day alone in a small cell), ranging from 14 days to 15 years. Almost half of the participants (45%) had been diagnosed with post-traumatic stress disorder. Table 2 describes the demographics of the study sample.\"}, {\"pmc\": \"PMC10838125\", \"pmid\": \"38314119\", \"reference_ids\": [\"fn0001\"], \"section\": \"\", \"text\": \"\\nYou get scared, I\\u2019m not going lie. You really do get scared because you never know if one day you might go through something that\\u2019s life-threatening and they have no solution for you. So, it\\u2019s like now your down at medical and you\\u2019re feeling like you\\u2019re damn near on your deathbed, and it\\u2019s like, the only thing they can tell you is, \\u201cOh you\\u2019ll be all right, here\\u2019s some Motrin.\\u201d Or, \\u201cYou\\u2019ll be all right, just sleep it off and come see us tomorrow.\\u201d So now it\\u2019s like, what if you do go back, and that\\u2019s your last sleep? (Melvin)\"}, {\"pmc\": \"PMC10838125\", \"pmid\": \"38314119\", \"reference_ids\": [\"CIT0045\"], \"section\": \"Theme #1: concerns about health contributing to sleep problems\", \"text\": \"The concerns expressed by both participants highlights an apprehension that all of the men expressed around worries about health and the distress that they caused. Our earlier work from this study [45], describes in detail the trauma the men experienced as a result of the healthcare they received in these carceral facilities. Illness and pain from health problems or injuries were routinely brought up by the men interviewed. In carceral settings, concerns about trust and privacy may additionally prevent people from seeking care and contribute to sleep problems.\"}, {\"pmc\": \"PMC10838125\", \"pmid\": \"38314119\", \"reference_ids\": [\"CIT0045\", \"CIT0056\"], \"section\": \"Discussion\", \"text\": \"Our results identify some ways the treatment of health conditions in carceral facilities can contribute to sleep problems and our earlier paper from these interviews highlights healthcare-induced trauma in carceral facilities [45]. A previous study of insomnia in incarcerated people found that those with insomnia were more likely to have a concurrent medical or mental health condition [56]. Concerns about health and the paucity of treatment options during incarceration, not just the health conditions themselves, contributed to insomnia and should be investigated in future studies.\"}, {\"pmc\": \"PMC10838125\", \"pmid\": \"38314119\", \"reference_ids\": [\"CIT0043\"], \"section\": \"Discussion\", \"text\": \"Few studies on sleep and incarceration have focused on what assessments, treatments, and interventions for sleep problems are available for this population. Medications commonly used to treat sleep in carceral settings include over-the-counter remedies like Benadryl or allergy medications and psychotropic medications like Remeron (anti-depressant) and Seroquel (antipsychotic) [43]. These medications may be used in lieu of insomnia medications used in community settings (e.g. Ambien, Lunesta, Belsomra) because the common causes of lack of sleep in carceral settings (anxiety, trauma, fear of violence) may be viewed as needing a stronger sedative to counteract. The use of these medications during incarceration may help sleep in the short term, but cause problems after release. Participants reported that they were often unable to get these medications from their primary care provider in the community, contributing to worse sleep after release. Noted by participants in this study and in our clinical, research, and lived experience, lack of access to sleep medication and CBT-I\\u2014options that are readily available to people outside the carceral system\\u2014exacerbates sleep problems, leading to mood changes that negatively moderate interactions with cellmates, other incarcerated people, and facility staff. Given the interconnected nature of trauma and trauma-related sleep problems, integrating CBT-I with PTSD treatment may improve the efficacy of sleep-related care in this population. Access to formal assessment and treatment for sleep disorders and comorbid mental health conditions during incarceration and after release could improve sleep health and reduce exacerbation and development of other health problems, improving mental health and social climate in facilities.\"}, {\"pmc\": \"PMC10838125\", \"pmid\": \"38314119\", \"reference_ids\": [\"CIT0042\", \"CIT0032\"], \"section\": \"Discussion\", \"text\": \"One study explored the use of interventions like mindfulness to improve well-being, using sleep as a secondary outcome, finding mindfulness-based emotional intelligence interventions decreased anxiety and depression and significantly improved sleep quality scores on the Pittsburgh Sleep Quality Index (PSQI) following intervention [42]. While CBT-I is commonly used to treat insomnia in community settings, it is not a treatment available in carceral settings despite its proven efficacy in this population. A study by Randall et al. [32] showed promising results using a one-shot CBT-I intervention to treat insomnia in incarcerated men, showing a reduction in the severity of insomnia and a reduction in depression and anxiety. A better understanding of the variety of sleep problems faced by incarcerated people and the factors contributing to sleep disparities in this population will aid in the adaptation and development of more population-specific interventions. Furthermore, a bolstered preventative care structure in carceral settings can reduce urgent care load and proactively improve sleep health.\"}, {\"pmc\": \"PMC10838125\", \"pmid\": \"38314119\", \"reference_ids\": [\"CIT0057\"], \"section\": \"Discussion\", \"text\": \"Rumination and nightmares were barriers to sleep, triggered by fear of violence in the carceral social environment. In carceral facilities, noise and violence often go together, with noise signaling events that could be disturbing to witness or directly experience. Even requesting others to be quieter can incite violence. One must choose between sleep and surviving the night. These coping tactics create a positive feedback loop in which sleep deprivation due to fear of violence propagates more violence. Lack of sleep has been shown to increase sensitivity to even minor events, resulting in inappropriately volatile retaliations [57].\"}, {\"pmc\": \"PMC10838125\", \"pmid\": \"38314119\", \"reference_ids\": [\"CIT0058\", \"CIT0005\", \"CIT0007\"], \"section\": \"Discussion\", \"text\": \"While here we focused primarily on how healthcare and trauma impact sleep, some participants did mention how factors in the physical environment can contribute to sleep problems. Adornetti et al. [58] highlight the impact of light and facility schedules on the sleep of juveniles in detention: issues in both juvenile and adult facilities that could be addressed to improve sleep. A recent review indicated the promise of addressing environmental characteristics to improve sleep, and emerging research identified sleep environment as an important modifiable mediator between sleep deficiency and worsening management of cardiovascular disease risk factors, including hypertension, diabetes, and obesity [5, 7]. Future studies should also examine how the physical environment in correctional facilities can affect sleep health.\"}, {\"pmc\": \"PMC10838125\", \"pmid\": \"38314119\", \"reference_ids\": [\"CIT0025\", \"CIT0031\", \"CIT0059\"], \"section\": \"Discussion\", \"text\": \"While past research has pointed to noise, light, facility elements, and sleeping conditions as potential causes of sleep problems in this population [25\\u201327, 31, 59], no studies have examined sleep after release from prison. The possible mechanisms of poor sleep health during incarceration and after release should be explored in future work to better understand and mitigate racial disparities in sleep health.\"}, {\"pmc\": \"PMC10838125\", \"pmid\": \"38314119\", \"reference_ids\": [\"CIT0060\"], \"section\": \"Conclusion\", \"text\": \"Although sleep is considered a basic need, it is rarely considered in research or programs focused on those impacted by the criminal legal system [60]. We identified new domains that may influence the sleep health of the millions of people with a history of incarceration. This work informs new understandings of how we must address sleep health disparities. Future work should focus on exploring sleep health more broadly among incarcerated people by conducting additional qualitative studies focused on sleep health in this population, studies to adapt existing sleep instruments to better assess sleep in this population, and larger studies that employ subjective and objective measures of sleep both during incarceration and after release. Explorations of sleep during incarceration focused on adapting and testing interventions for sleep and considering multi-level interventions that address sleep at the individual and carceral facility level (e.g. schedule, noise, light) are critical next steps in better understanding and addressing sleep in this population.\"}]"

Metadata

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