Start with an artificial sunset, dark bedroom, and artificial sunrise
STUDY: Wright KP Jr et al, J Clin Sleep Med 2026
STUDY TYPE: Clinical practice guideline with systematic review and meta-analysis
FUNDING: American Academy of Sleep Medicine
Background
About 27% of shift workers develop shift work disorder, defined as:
- At least 3 months of sleepiness at work or insomnia during off-hours
The American Academy of Sleep Medicine has updated its treatment guidelines, including a metaanalysis of 118 studies. Most of the studies, however, came from lab simulations rather than actual patients with the disorder.
Recommendations
For sleepiness at work, the guideline suggests:
- Armodafinil or modafinil 30 to 60 minutes before the night shift, the only FDA-approved drugs for the disorder and the only with moderate-certainty evidence. On an objective sleepiness test (MSLT), armodafinil 150 mg helped patients stay awake an extra 4.5 minutes; modafinil 200 mg an extra 1.4 minutes.
- Caffeine before or early in the shift (but not within 6 hours of sleep)
- Bright light during the shift
- A nap before the shift, alone or with caffeine
- A snack or no food overnight in place of a full meal
- Clockwise rotations (day, then evening, then night shift) rather than counterclockwise
For insomnia during daytime sleep, they suggest:
- CBT-insomnia adapted for shift workers (for app versions, try Insomnia Coach for CBT-insomnia and Clairoe for shift work)
- Melatonin (1.8 to 3 mg in most trials) before daytime sleep, which added about 18 minutes of sleep. It also helps before a pre-shift nap and when switching back to night sleep
- Ramelteon 8 mg before bed
- Suvorexant 10 to 20 mg, which added nearly 3 hours of sleep in one trial of 44 workers
- They recommend against benzodiazepines, because of falls, dependence, and withdrawal
For workers on fixed night shifts who want to shift their body clock, the guideline suggests bright light at night (ie, in their morning), a fixed daytime sleep schedule in a dark bedroom, and dark glasses on the morning commute (ie, before bedtime). This approach won’t help workers on rotating shifts.
Screen for sleep apnea and restless legs, which compound the problem.
Eight- and 12-hour shifts performed about the same.
Dr. Aiken’s Tips
Although the guidelines recommend a nap before the shift to reduce fatigue, that applies to a brief nap (30-90 min), not sleep. Night shift workers tend to fare better when they go to sleep after their shift, rather than right before. That strategy added 30 minutes to sleep time in a cross-over trial.
I cover more on melatonin and light/dark strategies for shift work in the Complementary and Alternative Medicine in Psychiatry Fact Book.
Practice Implications
- Start with behavioral steps, creating an artificial sunset (blue-light blocking glasses) before bed, artificial night (black out curtains) during sleep, and artificial morning (dawn simulator)
- Add light therapy upon awakening if fatigue is still a problem.
—Chris Aiken, MD
Director, Psych Partners
Editor in Chief, Carlat Psychiatry Report
