Shift work disorder occurs when a person’s work schedule repeatedly conflicts with their natural sleep-wake cycle, developing when work requirements overlap with an individual’s usual sleep timing for at least 3 months.
Symptoms may include excessive sleepiness, difficulty falling asleep, difficulty staying asleep, or a combination of these problems. These symptoms are associated with circadian misalignment, a mismatch between the body’s internal biological clock and the timing of work and sleep, as well as insufficient sleep.
Evidence suggests shift work disorder affects approximately 27% of adult shift workers and is commonly encountered in primary care and sleep medicine settings. The condition can make it difficult for people to remain alert during night shifts while also obtaining sufficient, restorative sleep during the day.
Now, a new clinical practice guideline from the American Academy of Sleep Medicine (AASM) outlines evidence-based approaches to managing shift work disorder in adults. Published in the Journal of Clinical Sleep Medicine, the guideline is accompanied by a systematic review and meta-analysis evaluating behavioral, pharmacologic, and circadian-based interventions for the condition.
The recommendations aim to help clinicians and patients identify appropriate treatment strategies based on individual symptoms, work schedules, and preferences. They also highlight the limitations of the current evidence, suggesting that treatment may need to be tailored to each person’s circumstances.
The AASM commissioned a task force of experts in sleep and circadian medicine to review the published scientific literature and develop updated recommendations. The accompanying systematic review and meta-analysis provide the evidence base for the recommendations and evaluate outcomes relevant to both patients and clinicians.
The recommendations cover several approaches to managing excessive sleepiness, insomnia symptoms, and circadian misalignment. The strength of the evidence varies between interventions.
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For adults experiencing excessive sleepiness during night shifts, the guideline suggests using armodafinil or modafinil to improve alertness. This recommendation is supported by moderate-certainty evidence.
The guideline also suggests considering other approaches, including caffeine, bright light exposure, strategic naps, and adjustments to meal timings. However, the evidence supporting these additional approaches is of low certainty. Their effectiveness may vary depending on individual circumstances, including shift timing and sleep patterns.
These strategies are intended to help manage sleepiness rather than eliminate the underlying circadian misalignment in every case.
Derk Krieger, MD, PhD, Professor of Neurology and Consultant Neurologist at Re:Cognition Health, who was not involved in the study, highlighted to Medical News Today that modafinil and armodafinil are among the better-supported medication options for excessive sleepiness.
“They can improve alertness and may help people function during night shifts. However, they do not correct the underlying disruption to the body clock and cannot replace adequate sleep. Side effects can include headache, nausea, dizziness and anxiety,” he noted.
“We also need more evidence about their long-term effects and whether improved alertness translates into fewer workplace or driving accidents,” he said.
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Some people with shift work disorder have difficulty falling or staying asleep when their work schedules require them to sleep at unconventional times.
For these symptoms, the guideline suggests cognitive behavioral therapy for insomnia (CBT-I), melatonin or melatonin receptor agonists, and certain hypnotic medications to support sleep in relation to work schedules.
Medication choice requires careful consideration of potential adverse effects, the timing of sleep and work periods, and the possibility of residual drowsiness. Treatments that help someone sleep may still affect alertness when they need to return to work or travel home.
“For workers whose main difficulty is sleeping after a shift, medicines that block orexin, such as suvorexant, may be considered,” Krieger explained to MNT.
“These medications target insomnia rather than sleepiness during working hours. However, evidence for their use in shift work disorder remains limited, and possible residual sleepiness after waking is an important safety consideration, particularly for people who drive or perform tasks requiring alertness.”
— Derk Krieger, MD, PhD
The guideline also considers interventions intended to help align the body’s internal clock with required working hours.
Suggested approaches include timed bright light exposure, maintaining a consistent sleep schedule when feasible, and using light-filtering strategies during the commute home.
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However, these approaches may not be practical for everyone. Rotating shifts, family responsibilities, and other constraints can make it difficult to maintain a regular schedule or follow a consistent light exposure plan.
The guideline emphasizes that no single treatment will work for everyone with shift work disorder. As people will have different schedules, symptoms, and practical constraints, making evidence-based treatment options that can be adapted to individual needs is important.
For example, a person who experiences severe sleepiness during overnight work may require a different approach from someone whose main difficulty is falling asleep after a shift.
Similarly, a treatment that is practical for someone working a stable night schedule may be less suitable for someone whose shifts change frequently.
The guideline therefore encourages shared decision-making between clinicians and patients. This approach allows treatment decisions to account for the available evidence alongside individual preferences, potential harms, and practical considerations.
“Shift work disorder represents a significant unmet need in sleep medicine,” Krieger emphasized. “Many workers may regard persistent sleepiness or difficulty sleeping as an unavoidable consequence of their jobs, rather than a condition that can be recognized and managed. We also need more research into treatments that provide lasting benefits and improve both health and workplace safety.”
“The key message from the new clinical practice guidelines is that shift workers may need different treatments depending on their work schedules and symptoms. Someone who struggles to stay awake during a night shift has a different problem from someone who cannot sleep after finishing work. A single approach is unlikely to suit everyone.”
— Derk Krieger, MD, PhD
“Treatment should also reflect the type of shift pattern,” Krieger explained. “People working permanent nights may benefit from carefully timed light exposure and a consistent daytime sleep schedule to help their body clock adjust partially. For rotating-shift workers, repeatedly trying to reset the body clock may be impractical; managing symptoms and protecting sleep opportunities may be more appropriate.”
Although the guideline provides updated recommendations, the authors highlight that the quality of evidence for many interventions remains limited.
Some strategies are supported by moderate-certainty evidence, while others rely on low-certainty findings. This distinction is important because the certainty of the evidence influences how confidently clinicians can anticipate benefits.
Treatment decisions must also account for potential harms. Improving alertness during a shift, for example, does not necessarily mean that a person will obtain adequate sleep afterward. Likewise, medications used to support sleep may cause side effects that affect subsequent waking activities.
Further research is necessary to clarify which interventions work best for different groups of shift workers, how treatments should be timed, and how benefits and risks vary across individuals.
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The guideline does not present one universal treatment plan. Instead, it provides clinicians with an evidence-based framework for selecting and adjusting interventions according to patients’ needs.
The new guideline offers a structured starting point for managing shift work disorder, with options ranging from behavioral interventions and carefully timed light exposure to medications that target sleepiness or insomnia.
However, the appropriate approach depends on the symptoms a person experiences, their work schedule, and the potential benefits and risks of each intervention. Ultimately, the recommendations underscore the importance of treating shift work disorder as an individual clinical problem rather than assuming that one strategy will work for everyone.
“Importantly, all the recommendations in the new guidelines are conditional, reflecting limitations in the available evidence,” Krieger concluded.
“These guidelines are a useful step forward, but they are not a one-size-fits-all solution. More research is needed to establish which treatments work best for different workers and whether they improve long-term health and safety.”
— Derk Krieger, MD, PhD
People who regularly experience excessive sleepiness during work or difficulty sleeping around their shifts may benefit from discussing these symptoms with a healthcare professional. A clinician can assess whether the symptoms are consistent with shift work disorder and consider suitable treatment options.
