A cross-sectional comparative study of insomnia , depression , and suicidality between male and female prisoners of Guwahati Central Jail

Background: Female prisoners are consistently reported to suffer more from insomnia, affective disturbances, and higher suicide rates than males. Objective: To compare the prevalence of insomnia, depression, and suicidality between male and female inmates, and to probe how the internal turmoil and the psychological burden consequent of Method: Forty male and 40 female prisoners of Guwahati Central Jail, Assam, India were assessed clinically and Beck Depression Inventory II, Pittsburgh Insomnia Rating Scale, and Columbia Suicide Severity Rating Scale were administered. Appropriate statistical tests for categorical


INTRODUCTION
e recent times had witnessed a shocking upsurge of crimes all throughout the world.[1] In the recent years, India had also become a crime hub with a total violent crime rate of 24.4 per 100, with rape (5.7%), kidnapping (5.3%), and murder (2.7%) topping the list of violent crimes.[2] e prison environment was traditionally been described as an "intrinsically non-therapeutic" environment.[3] e restriction of basic human rights coupled with the unhealthy overcrowding (the total prison occupancy rates in India and the state of Assam were 118.4 and 101.9 per the o cially allotted quota of 100 respectively) [4] lead to anaemia, malnutrition, bacterial and viral infections, dermatitis, asthma, musculoskeletal diseases, and most alarmingly, tuberculosis and HIV/AIDS; which were reported to be much higher in prisoners than in general population.[5][6][7] Prevalence of mental illness among prisoners was also recognised to be very high globally with a wide range of prevalence, [8,9] which was precisely replicated by Indian studies (33% to as high as 79.9%).[10,11] Any neurotic problem [12,13] as well as sleep disturbances [14][15][16] and mood disorders, particularly depression were very much rampant in the prisons, with depression showing a wide range from 4.2% to 25.5%, [17,18] which went upwards to 62% in exclusively female prisoner studies.[19] Despite this important gender bias that was observed in a few comparative studies, [17,19] no speci c literature was found trying to probe this di erence.e inmate suicide rate also consistently exceeded the suicide rate for the general population, more so in case of female inmates.[20,21] Apart from the unfavourable conditions in prison, realisation about the nature of the crime committed, guilt feelings, and the progressively increasing isolation from society made the prisoners fragile from inside.Although our study design does not allow us to infer causality, this study is a humble attempt to nd the impact of psychological trauma of being incarcerated upon the development of these psychiatric morbidities in the prisoners of this region.

Aims and objectives
e primary objective of the study was to compare male and female prisoners in regard to the prevalence of insomnia, depression, and suicidality.Secondly, the authors wanted to assess the relationship of insomnia, depression, and suicidal behaviour with the study variables of duration of stay in jail, the penal status, nature of crime, lifetime substance abuse, and physical morbidity; separately in male and female prisoners with a special emphasis upon the separation from their children in case of female prisoners.

MATERIALS AND METHOD
e study was conducted with the prisoners from Guwahati Central Jail, located near Sarusajai stadium, Lakhara Chariali, in the Kamrup district of Assam, India.e period of study extended from January 2012 to December 2012.O cial permission from Inspector General of Prisons, Assam was obtained to interview the prisoners.e study design was that of a cross-sectional comparative study, and the sample size consisted of 80 consecutively selected male and female prisoners (40 each for male and females) from the Guwahati Central Jail, matching the gender at the study intake.e sample size calculation was based upon the prevalence of prison depression published in two separate studies conducted upon male [22] and female prisoners.[19] We used the formula, patients per group = p 1 (1-p 1 )+p 2 (1-p 2 )/(p 2p 1 ) 2 x f(α,β), [23] where p 1 was the prevalence of depression in male prisoners (35%) and p 2 was the prevalence of depression in female prisoners (63%) according to the two above mentioned studies.e power was xed at 80% and the level of signi cance was ve per cent, the value of f(α,β) was 7.85.e obtained sample size for each group applying this formula was 41.1 which was rounded to 40 for each group.Both male and female prisoners aged 18 years and above were included in the study.Prior ethical approval was obtained from the Institutional Ethics Committee, Gauhati Medical College before commencement of the study and con dentiality was maintained regarding the information which was obtained from the prisoners.Subjects, literate either in English, Assamese, or Bengali were only included in the study.Subjects having previously diagnosed psychiatric illness or obvious mental retardation prior to intake into the study were excluded from the study, as well as those who were having severe hearing or visual impairment.Subjects having serious medical illness were also excluded from the study.

Procedure
ose prisoners who ful lled the inclusion and exclusion criteria were explained the purpose and procedure of the study.A er taking informed and written consent, the prisoners were subjected to formal psychiatric history and mental status examination, and were interviewed using the sociodemographic and the other clinical variables questionnaire as described below.For statistical purpose, the continuous clinical variable of duration of prison stay was categorised into three groups of six months, six months to one year, and more than one year as three discrete categories.For the same reason, age of children was categorised by ve years incremental groups for female prisoners having children.e prisoners were given the choice of selecting psychological or pharmacological interventions had they been found to su er from clinically impairing morbidity.

Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV-TR)[24] 2. Beck Depression Inventory-II (BDI-II)[25] 3. Pittsburgh Insomnia Rating Scale (PIRS) [26] 4. Columbia Suicide Severity Rating Scale (C-SSRS) [27] 5. Sociodemographic Variable Questionnaire BDI-II, created by Dr. Aaron T. Beck, was a 1996 revision of the BDI, to be compatible with DSM-IV.It was a 21-item, multiple choice, self-report inventory, each answer being scored on a scale value of zero to three.[25] e authors of the scale recommend following ranges of BDI-II cut-o scores for depressionero to 13 (minimal), 14-19 (mild), 20-28 (moderate), and 29-63 (severe).e test was shown to have a high one-week test-retest reliability (Pearson r is 0.93), and also a high internal consistency (α=0.91).For the purpose of use in the current study, BDI-II had been translated into Assamese and Bengali languages for the prisoners not well versed with English, and was validated subsequently in the Psychiatry Department of the study institution.
PIRS was a widely used instrument in clinical and research practice.[26] It is a scale with 65-items with three broad sections; the subjective distress score (46 items), subjective sleep parameters (ten items), and last is the quality of life (QOL) score (nine items).e minimum and the maximum score ranged from zero to 195.Prevalence of insomnia was calculated by dividing the continuous variables of sleep distress, sleep parameters, and QOL into three tertiles, and taking the second and third tertile as implying clinically signi cant impairment.
is strategy of dividing into tertiles was piloted upon samples of ten male and ten female prisoners each, and found to have correlated well with clinical observation of signi cant insomnia as interviewed by two of the study authors independently.PIRS demonstrated good test-retest reliability and it measured severity of insomnia in the past week of assessment.It appeared to have good concurrent validity with the Pittsburgh Sleep Quality Index (PSQI).[27] For the purpose of this current study, PIRS had been translated into Assamese and Bengali version, and had been validated accordingly.
C-SSRS is a suicidal ideation rating scale created by researchers at Columbia University to evaluate suicidality in children of ages 12 and above.[28] It rated an individual's degree of suicidal ideation on a scale, ranging from 'wish to be dead' to "active suicidal ideation with speci c plan and intention". is measure contained six "yes" or "no" questions in which respondents were asked to indicate whether they had experienced several thoughts or feelings relating to suicide over the past month.ese questions measured severity of di erent components of suicidal ideation.e intensity of the suicidal ideation subscale had demonstrated strong internal consistency.

Statistical analysis
Statistical analysis was done using descriptive statistics and mean values were calculated for continuous variables.Chi-square (χ 2 ) test and Student t test were performed as required for the comparison analysis.Con dence interval was xed at 95% and a p value of 0.05 was taken as being statistically signi cant.For the association analysis, χ 2 test for independence and χ 2 test for trend were used wherever indicated.We used GraphPad Prism 6.02 (March 2013) for data analysis and statistical calculations.

Sociodemographic and crime related variables analysis
As shown in Table 1, mean age of the study population was 36.75 years (SD=10) and Hinduism was the dominant  religion.Female prisoners as a group had signi cantly more divorced and widowed participants (χ 2 =12.913, df=2, p<0.01).Educational attainment was low and majority of them were daily wage earners from lower middle socioeconomic status of rural background.e ndings from the parameters related to incarceration were tabulated in Table 2. e males served terms signi cantly longer than females (combining six months to one year and more than one year as a single category,  χ 2 =14.066, df=1, p<0.001).Signi cantly more males were convicted than female prisoners, χ 2 test p value being 0.04.

Comparison between sexes for prevalence of insomnia, depression, and suicidality
Eighty ve percent of the female prisoners su ered from depression in comparison to 62.5% of the males (χ 2 test for independence=8.298,df=3, p=0.04).e prevalence of sleep distress in males was 65% and that in females was 72.5%.Prevalence of sleep parameter impairment was 62.5% in males and 82.5% in female prisoners, and that of sleep QOL impairment was 57.5% and 87.5% in male and female prisoners respectively.Male and female prisoners did not di er in respect to their sleep distress or sleep parameter, sub-scores in PIRS (p value being 0.66 and 0.09 respectively).But, a signi cantly higher number of females had poorer QOL when compared to male prisoners (QOL, χ 2 test for independence=9.836,df=2, p<0.01).
When C-SSRS scores are examined (Table 3), females signi cantly outnumbered males as 30% of them had suicidal ideation in comparison to only ten per cent of the males having such ideas during the stay (p<0.05,relative risk=0.33,95% CI=0.117-0.946).Only one female prisoner (2.5%) had both suicidal behaviour and suicidal attempt, whereas no male prisoner had any suicidal behaviour or attempt.

Association of crime related variables with depression, insomnia, and suicidal ideations
Male prisoners had no statistically signi cant association of their duration of prison stay either with depression, insomnia, or suicidal ideation (Table 4[A]).But, female prisoners, who were imprisoned for more than six months, had more severe degrees of depressive symptoms (χ 2 =4.718, df=1, p<0.05) and signi cantly more suicidal ideation (χ 2 =4.622, df=1, p<0.05) than those who stayed in prison for shorter term.Males were more depressed while they remained under trial than when they were convicted (χ 2 =3.851, df=1, p<0.05) which was the opposite nding in case of female prisoners (Table 4[A]).Apart from male rape convicts who had signi cantly more suicidal ideation (χ 2 =8.120, df=1, p<0.01), no statistically signi cant association was found between nature of crime and depression or insomnia in both male and female prisoners (Table 4[A]).It was seen that male prisoners who used substance ever in their lifetime were signi cantly more depressed than those who did not (χ 2 =7.332, df=2, p<0.05), while those female prisoners who ever used substance had signi cantly more suicidal ideation (χ 2 =5.448, df=1, p<0.05).Another striking result of the analysis (Table 4[B]) was that those male prisoners who had any form of physical illness were signi cantly less depressed (37.5%) than those who did not have any illness (81.25%) (χ 2 =4.146, df=1, p<0.05), while physically ill females had more suicidal ideation as expected (χ2 =4.750, df=1, p<0.05).A statistically signi cant association was found in case of mothers for all three dependant morbidity variables in comparison to females who did not have children (Table 4[B]), with the strength of association increasing with increasing number and age of their children (χ 2 test for trend=8.486,df=1, p<0.01 for insomnia and χ 2 test for trend=9.884,df=1, p<0.01 for suicidal ideation).

DISCUSSION
Internalising psychiatric disorders or distresses were reported by many researchers to be more prevalent in prison inmates than in general population.[14,21,29] Females used to su er more from these morbidities than male prisoners [17,19] and the signi cantly more divorced, widowed, and homemaker females found in our study in contrast to their employed and married male counterparts, highlighted the importance of such basic demographic characteristics in comparative prevalence of such morbidities.

Analysis for the primary objective
A recent Indian prison study [29] found the prevalence of clinical depression in prisons to be 16.1% and international studies reported such varied rates as 5.04% [30] to even 91% in one study.[13] In line with that, our comparative study in two representative samples of male and female inmates came up with very high estimates, and the di erence between the genders assumed statistical signi cance.Other researchers also previously reported this important sex di erence.[11,19] Now, coming to the issue of sleep disturbance, nearly three quarters of the male inmates and four hs of the females in our study had sleep impairment in all the three subscales of PIRS, and the female inmates had signi cantly poorer QOL due to sleep impairment in comparison to their counterparts.Both the external factors related to overcrowding, the unavoidable human rights restrictions and lack of appropriate health resources [15,16] as well as the internal turmoil that the prisoner went through while being incarcerated [14] were deemed responsible by many previous 5.448 (0.0196) †Male prisoners had more depression associated with under-trial penal status.‡Comparing murderers with other male criminals, including rapists, as other category of criminals did not have any suicidal ideations.BDI-II: Beck Depression Inventory-II, PIRS-QOL: Pittsburgh Insomnia Rating Scale-Quality of life, C-SSRS: Columbia-Suicide Severity Rating Scale.authors for such high prevalence of sleep disturbances.On the other hand, we found much less prevalence of suicidal ideation or attempt in our prisoners, which was reported to be much higher in previous studies done outside India.[20,31,32] is was a consistent nding all over the world, as in the Bangalore prison study [11] six out of the total 30 deaths were found to be due to prisoner suicide against a national backdrop of 10.6 suicides per one lakh general population.[33] A recent study done in Australia even reported a staggering h of the total studied prisoners attempting suicide.[34] Although solitary con nement [21] and prisoner abuse, overcrowding, and hopelessness [20,21,29,32] were put forward as explanations, the literature still lacks causal explanations for this overwhelming rate of prisoner suicide.

The association analysis
A general trend of increased vulnerability for these morbid occurrences was seen in female inmates in comparison to their male counterparts.For example, in females, the severity of depressive symptoms increased as a function of time as well as a change in the penal status from under trial to conviction.
is association of morbidity regarding convict status and subsequent longer duration of stay was evident also with suicidal ideation in female inmates but not in males.In fact, male prisoners had less depression once they were convicted of their crimes.is nding posed an intriguing question as to what conferred the males with such signi cant resilience that in place of getting broken down to depression, they actually were able to cope better as their stay lengthened in prison.One probable but untested explanation might be that male prisoners were relieved of the apprehension and panic once they were convicted of their crimes, and were able to accept and adjust more rapidly in the prison environment than females.Exactly what conferred them with this impressive resilience was obviously out of purview of our study, and supposedly involved numerous biological and environmental variables, and is a fertile ground for future studies.Another interesting nding of the study was that all of the male prisoners who were tried or convicted of rape had expressed suicidal ideation.is reached statistical signi cance when compared to other categories of crime committed by male o enders.Why all the rape perpetrators would harbour suicidal ideation was something we were unable to explain, and further studies are needed drawing upon a much larger sample of prisoners to validate this nding and to look for an explanation.In the current study, another association worth nothing was between substance abuse and depression.A statistically signi cant association was found between lifetime substance abuse and depression in male prisoners.As reported by a recent researcher, a lifetime history of substance use predisposed the prisoners for development of depression; still worse, if the prisoners were originally convicted for a substance related crime.[35] e present study cannot claim causal associations because of the study design, but testi ed to the validity of such a gloomy scenario at least in the cross-sectional observation which needed further long-term studies to con rm the association.Another nding from the current study was in stark contrast with previous ndings.As we have mentioned earlier, a major bulk of the prisoners in our study did not su er from any physical illness and in the attempt to associate physical illness with depression, it was found that male prisoners who were su ering from chronic physical illness were actually su ering signi cantly less from clinical depression in comparison to the ones having any physical illness.We were unable to nd any literature supporting this nding and were le only to speculate if the physical illness were allowing them to at least remain preoccupied with something else, and rescued them from the pervasive feeling of boredom and the torturing whiplashes of their relentless conscience.One of the most interesting ndings from our study pertains to the statistically signi cant di erences in prevalence of depression, poor sleep quality, and suicidal ideation between the group of female prisoners who had children when compared with those who did not have any children.is nding had been previously reported by the large Bangalore prison study where the researchers had found separation from children as an important factor impacting women prisoners' psychological health.[11] Age of their children also signi cantly a ected their wellbeing as those who had very young and adolescent children were a ected more.Traditionally, women are considered more caring and psychologically sophisticated than males, and they are also more vulnerable for internalising disorders.[36,37] One could logically infer that the motherly instinct and the inherent biological vulnerability would make mothers su er more from these psychological morbidities once they were separated from their children due to imprisonment.

Strength and limitations
e present study was limited in some important aspects.e rst important limitation was an unavoidable selection bias due to the cross-sectional study design and serial sampling procedure in the form of probable inclusion of prison inmates who might have already been su ering from depression or insomnia or harbouring suicidal ideation prior to their incarceration.is was attempted to be minimised by selection of rating scales which asked questions about their psychological and behavioural functioning in the cross-sectional time frame or the preceding week prior to the study intake.Another issue of concern to the authors was that the independent clinical variables which were tested for supposed association with the dependent outcome variables of morbidity, were themselves seemed to be related to each other, and more exhaustive regression analysis was needed to address this issue.Finally, the study participants were not followed-up for test-retest reliability as the study design did not permit, but all of them were separately examined by the authors to ensure the validity and reliability of the clinical diagnosis.

Conclusion
is was the rst study as per the authors' knowledge, to be conducted in the North-Eastern part of India which looked inside the prisoners' troubled world.Although clinical data were available from various Indian studies regarding the general and mental health conditions inside the prisons in India, that data was limited only to prevalence estimates of various morbidities.
is was the rst attempt to trace any link between the selfrealisation, pervasive isolation from society and children, and detrimental e ects of substance abuse and physical ill health upon the psychological wellbeing of the incarcerated.e authors deliberately kept aside factors related to unhygienic prison conditions, overcrowding, prisoner maltreatment and abuse, deprivation and humiliation of basic human rights of the prisoners, and poor infrastructure issues of the jails as many authors highlighted these issues previously.What came out from this study was an unusually high prevalence of depression, sleep disturbance, and suicidal ideation in the prisoners of both the sexes in comparison to the general population, although female inmates had su ered signi cantly more from these morbidities.More statistically and methodically rigorous studies spanning over an entire prison population and following a longitudinal design in the future may be able to validate these important ndings that the current study brought forth.Taking into consideration the immense unmet needs of the prison population in terms of mental health and wellbeing, such studies in the immediate future are the call of the hour.

Figures
Figures indicate the number of prisoners in each category with percentages in parentheses.

*
Figures indicate the number of prisoners in each category with percentages in parentheses.

Table 3 :
Distribution of prisoners falling in different ranges of cut-off scores for the tools for assessment of depression, insomnia, and suicidal ideationseverity rating scale (C-SSRS):

2
test for independence (p value) Females having children of different age (less than 5 years/5 to 15 years/more than 15 years) Any physical illness (yes*/no) (0.0226) § ‡ANOVA P values (comparing mean BDI-II scores of females in less than 5, 5 to 15, and more than 15 years age group categories of their children).

Table 1 :
Distribution of sociodemographic variables among the prisoners

Table 2 :
Distribution of prisoners according to different categories of incarceration variables

Table 4 [
A]: Association analysis of the crime related variables with depression, insomnia, and suicidality