Finding better answers for sleep disorders: shift happens; Treatment options for sleep disorders are expanding rapidly, leading to paradigm shifts regarding what constitutes a treatable condition, what treatments are available, and how long to treat.(Essential PsychopharmaStahlogy)

The psychopharmacology of sleep disorders is awakening from a long slumber. The modern psychopharmacologist must become an expert on the current diagnosis and treatment of disorders of sleep and wakefulness.

The neurobiological understanding of sleep disorders has advanced significantly in recent years and is now leading to a renaissance in treatment. (1,2) These developments are bringing the diagnosis and treatment of sleep disorders increasingly into mainstream psychopharmacology. In the past, psychopharmacologists may have considered sleep disorders somewhat exotic, to be diagnosed with fancy and expensive equipment by sleep subspecialists and lacking psychopharmacologic treatments other than abusable stimulants or dependence-causing hypnotics. Today, however, treatment options for sleep disorders are expanding rapidly, leading to paradigm shifts regarding what constitutes a treatable condition, what treatments are available, and how long to treat.

"New" treatable conditions and their treatments

Although narcolepsy and cataplexy have long been recognized as important, if rare sleep disorders, it is now known that several other diagnosable and treatable conditions are much more common and also disrupt sleep and impair daytime wakefulness. These include shift-work sleep disorder (treatable with modafinil), (3) obstructive sleep apnea (treatable with modafinil augmentation of CPAP, continuous positive airway pressure), (3) chronic insomnia (now treatable with chronic administration of hypnotics such as eszoplicone and others in development that do not seem to cause dependence), (4) and restless legs syndrome (treatable with pramipaxole and other dopamine agonists). (5)

These sleep disorders must now be considered as the possible cause of symptoms when evaluating a patient with treatment-resistant depression, cognitive dysfunction, insomnia, or excessive daytime sleepiness. Likewise, symptoms of wakefulness at night and excessive sleepiness in the daytime should also be evaluated as possibly being secondary to another psychiatric or medical disorder, pain, or psychotropic medication.

Sleep disorder or cosmetic psychopharmacology?

No one would argue that the treatment of sleep deprivation due to partying or overwork is sleep, not a drug. However, it is now clear that up to 25% of shift workers have shift-work sleep disorder and thus have more than a problem with their lifestyle. Individuals with shift-work sleep disorder require evaluation for treatment of sleepiness during their working hours as well as during the times when they must drive to and from work. Figure 1 shows the correlation between traffic accidents and the daily rhythm of sleepiness, (6) suggesting that individuals who must sleep during odd hours, work during odd hours, and drive to and from work need to be evaluated for treatment. Such treatment would include hypnotics that promote sleep when they have the time to sleep and wake-promoting agents such as modafinil when they must work and drive.