Managing the patient with shift-work disorder

Although few interventions have been studied specifically among individuals with SWD, there are a range of practical steps that clinicians can offer to relieve its adverse effects and to reduce a patient's risk of experiencing the potentially fatal consequences of this disorder. Appropriate interventions include steps to improve sleep hygiene, and evaluation and appropriate referral for comorbid conditions, with particular emphasis on comorbid sleep disorders. Strategies to promote adaptation to the required sleep/wake cycle should also be implemented. These can include bright light therapy (before or during a night shift), reduction of exposure to daylight on the commute home from work, and/or medication with melatonin before a required sleep period, or combinations thereof.^32,34,36,66 These strategies have proved useful among shift workers in general, and further investigation of such strategies would be valuable among those with SWD. Steps to improve shift schedules (eg, the use of clockwise-rotating shifts and avoiding shifts longer than 12 hours), and measures to improve shift-work conditions, such as bright light exposure and appropriately timed naps, may also be helpful. The wakefulness-promoting agents modafinil and armodafinil are the only interventions with FDA approval for use in patients with SWD and have been evaluated specifically among individuals with ES associated with SWD. These agents have been proven to reduce ES during the work period, with associated benefits in terms of a reduced incidence of accidents or near misses during the commute home. Initiation of wakefulness-promoting therapy should be considered early in the management of individuals with SWD. Future research should focus on the potential of interventions known to promote wakefulness or sleep specifically among individuals with SWD. In the meantime, clinicians caring for individuals with SWD should develop individualized management strategies that incorporate both nonpharmacologic interventions and pharmacologic therapies, such as a wakefulness-promoting agent before the work period with or without a sleep-promoting agent before the required sleep period.