Evolution of Sleep Medicine in Thailand

Professor Dr. Arunnawan Pruthipan

Humans spend one-third of their lives sleeping. Most of the knowledge related to sleep medicine comes from abroad, especially the United States, where there has been a tremendous surge in research and studies in this field since the discovery of rapid eye movement (REM) sleep in 1953. Research in both medical and scientific fields has led to the development of a specialized discipline, sleep medicine and sleep science. There are now sleep specialists, and a profession known as sleep technicians or sleep technologists, who conduct sleep studies in laboratories through polysomnography. There are professional associations and foundations dedicated to the advancement of knowledge and care for individuals with sleep disorders. Annual conferences are held at both the national and international levels, and academic journals are published. Training exams are organized to standardize the expertise of sleep specialists and to award certificates in sleep medicine. In addition, sleep centers across the country are accredited for quality. Some universities in the United States have established sleep medicine as a department or division under the name Department or Division of Sleep Medicine.

Sleep medicine is considered a new field in the medical profession when compared to other specialties. The level of development in this field varies greatly from country to country. In Thailand, there is no separate division of this specialty as of yet. Instead, the study of sleep is integrated into various medical disciplines, such as neurology, psychiatry, respiratory medicine, otolaryngology, and dentistry. It also extends to preclinical levels and basic medical sciences, including sleep physiology, pharmacology related to sleep medications, neuroscience, neurobiology, and behavioral science.

The History of Sleep Medicine in Thailand

Over the past 20 to 30 years, Thai people have increasingly recognized the importance of sleep medicine. Thai doctors and scientists have started to explore and conduct research on sleep-related issues. This research initially focused on two primary sleep-related diseases commonly found in Thailand:

Sudden Unexplained Death Syndrome (SUDS) or Sudden Unexplained Nocturnal Death Syndrome (SUNDS): This condition caused widespread alarm from 1982 to 1990, as it was found that 235 Thai men, mostly from northeastern Thailand and aged around 33, who had worked as manual laborers in Singapore, suddenly died without an apparent cause. This sparked significant concern.

This situation provided an opportunity for Associate Professor Dr. Naipinij Kochphakdee, a renowned international expert in neuroscience, to establish the first polysomnography laboratory in Thailand at Mahidol University, Salaya campus, in 1984 (Figure 1).

The research to identify the cause of this disease primarily focused on the possibility of heart muscle abnormalities and electrical signaling in the heart. While the cause was not definitively established, reports suggested that it could be linked to ventricular fibrillation, triggered by low levels of potassium (K) in the blood, which might have resulted from low-potassium diets.

Obstructive Sleep Apnea (OSA): This condition, involving the obstruction of the airway during sleep, was explored by Associate Professor Dr. Kanit Mantraporn, who pioneered the use of polygraphic tests to diagnose sleep apnea in 1974. He also reported the first uvulopalatopharyngoplasty (UPPP) surgery for snoring in Thailand in 1988 (Figure 2).

Following these initial efforts, several universities and major hospitals began establishing polysomnography laboratories for sleep studies. These efforts involved multidisciplinary collaboration, with pioneers in this field including Professor Dr. Phune Kasem Charoenphan (respiratory diseases), Associate Professor Dr. Kanit Mantraporn (otolaryngology), Professor Dr. Prasert Boonkerd (neurology), Assistant Professor Dr. Surachai Kueasirikul (psychiatry), Assistant Professor Dr. Taiat Deesutjit (pediatric neurology), and Professor Dr. Arunnawan Pruthipan (pediatric respiratory medicine).

Later, several Thai physicians who received training in sleep medicine in the United States and Canada returned to Thailand to advance the field further. Many of these doctors earned prestigious certifications, such as the American Board of Sleep Medicine, Certified International Sleep Specialist, and Registered Polysomnographic Technologist (RPSGT). These developments have been pivotal in pushing forward the field of sleep medicine in Thailand, setting higher standards for the care and treatment of patients with sleep disorders, both now and in the future.

Establishment of Professional Associations Related to Sleep

In 1991, Associate Professor Dr. Naipinij Kochphakdee established the Thai Sleep Research and Sleep Medicine Society (TSRSMS) with support from the Asian Sleep Research Society. The society organized the first international academic conference in Thailand three times: The 3rd Congress of Asian Sleep Research Society (ASRS) in Bangkok, held from December 3-8, 2000. The 9th International Congress of Behavioral Medicine in Bangkok, held from November 29 to December 2, 2006. The 2nd World Congress of the World Association of Sleep Medicine (WASM) in Bangkok, held from February 4-8, 2007.

These events marked a significant beginning in gathering Thai physicians and scientists interested in sleep to meet, consult, and demonstrate Thailand’s academic potential to international scholars.

Later, in 2009, Professor Dr. Praphan Yongjaitit and Professor Emeritus Dr. Kunanta Maranet jointly established the Sleep Society of Thailand. The board members included sleep medicine specialists from various royal colleges. The society’s goals included:

To support and promote the field of sleep medicine in Thailand, advancing education, research, and medical services.

To improve knowledge and understanding of sleep among doctors, sleep technicians, and related medical personnel, as well as scientists and the general public.

To promote the standardization of care for sleep-related diseases, diagnostic tests, and treatments to meet international standards.

As of 2017, the society had 190 physician members and 241 sleep technician members. Since its establishment, the society has held an annual academic meeting. Additionally, the society has organized training for sleep technicians, conducted exams for sleep medicine specialists and sleep technicians at both basic and advanced levels, and assessed the quality of polysomnography tests. It also produced clinical practice guidelines, academic textbooks, and provided public education through various media outlets, in collaboration with the Department of Health, Ministry of Public Health, for World Sleep Day, held on the second Friday of March each year. This event aims to promote correct knowledge and understanding of sleep to the public across the country.

Problems in the Development of Sleep Medicine in Thailand

The most significant problems and obstacles in the development of sleep medicine in Thailand include the shortage of sleep technicians and specialists in sleep medicine, as well as the lack of standardized sleep laboratories. Currently, only government employees and employees of state enterprises are able to claim reimbursement for sleep studies and the cost of CPAP (Continuous Positive Airway Pressure) machines, while those with private health insurance are unable to claim these costs. Additionally, patients under the Universal Health Coverage scheme cannot claim for the purchase of CPAP machines, but they can request to be sent for a sleep study at a government hospital.

This situation creates disparities in access to healthcare services, leading to inequality in patient care. Many patients diagnosed with severe obstructive sleep apnea and associated complications do not receive treatment because they fall into categories that cannot claim healthcare costs.

Aside from treatment, Thailand also lacks basic data on the sleeping habits of its population. Research in this area is very limited compared to other countries in Asia, such as Taiwan, South Korea, and Hong Kong.

Guidelines for the Development of Sleep Medicine in Thailand

• Physicians
• Sleep Technicians
• Sleep Studies and Laboratories, and Other Aspects
• Research
• Public Awareness

Physicians

It is a great opportunity that a number of Thai doctors interested in the field of sleep medicine have had the chance to further their knowledge and training in the United States and Canada. They gained qualifications and experience in managing sleep-related disorders and most returned to work in medical schools and leading hospitals in Thailand. Once the Sleep Disorder Society was established, these qualified physicians collaborated and worked together to advance the field of sleep medicine in Thailand.

In 2010, the Sleep Disorder Society organized the first sleep medicine specialist exam in Thailand, using the MCQ exam from Dr. Clete A. Kushida, who was the president of the American Academy of Sleep Medicine (AASM) at the time. Ten Thai doctors passed the exam and received certification as sleep specialists from the Sleep Disorder Society. These specialists became the core team working with the society. Since then, the society has organized exams for doctors from all over the country every year. By 2017, 32 doctors had passed the exam.

In addition to increasing the number of sleep medicine specialists, the society has organized an annual academic conference and hosted an international conference, the 2nd ASEAN Sleep Congress in 2013 at Chulalongkorn Hospital.

In 2016, as a result of the efforts of the Sleep Society of Thailand and various Royal Colleges, the Medical Council of Thailand approved the establishment of a subspecialty residency training program in Sleep Medicine. This program was placed under the supervision of four Royal Colleges: the Royal College of Otolaryngologists, Physicians, Psychiatrists, and Pediatricians. It was anticipated that the first training program under the Royal College of Otolaryngologists would commence in 2018, with the remaining three colleges expected to follow in the near future.

In addition, one-year post-residency certificate training programs in Sleep Medicine have been offered at Chulalongkorn Hospital, Siriraj Hospital, and Ramathibodi Hospital since 2011, 2015, and 2017, respectively. Furthermore, a Master of Science (MSc) in Sleep Medicine program has been established at both Siriraj and Ramathibodi Hospitals since 2015.

It is believed that, in the future, Thailand will have an increasing number of sleep medicine specialists to meet the growing demand from patients nationwide.

Sleep Technicians

The shortage of sleep technicians has long been one of the most significant obstacles to the development of sleep medicine in Thailand. In the early years, most technicians were trained informally through hands-on experience alongside physicians who had completed formal training abroad. These early technicians primarily relied on guidelines for interpreting polysomnography from the American Academy of Sleep Medicine (AASM).

In 2004, Dr. Pundarika Suwanpakdee organized the first Polysomnography Workshop at the Department of Physiology, Faculty of Medicine Siriraj Hospital. The event was honored by the participation of Dr. Sharon Keenan from the School of Sleep Medicine, Palo Alto, USA, as the keynote speaker.

Following the establishment of the Sleep Society of Thailand in 2009, the society recognized the urgent need to train more sleep technicians. Since 2010, the society has organized annual hands-on training workshops specifically for sleep technicians. These workshops are led by sleep specialists and experienced technicians and include lectures, simulated patient scenarios, and computer-based training. Each year, the workshops attract 50–100 participants.

In 2015, the society hosted an international Polysomnography Workshop at Ramathibodi Hospital, with Dr. Sharon Keenan and Dr. Tripat Deep Singh as key speakers. This event drew participants from Thailand and six other countries.

The society also holds annual certification examinations for sleep technicians, divided into two levels: Basic and Advanced. The assessments include multiple-choice questions (MCQ), Objective Structured Clinical Examinations (OSCE), and individual computer-based scoring competency tests. As of 2016, 82 technicians had passed the Basic level, and 27 had passed the Advanced level. A notable achievement in that year was Mr. Worakot Suwansatit, Chief Sleep Technician at Ramathibodi Hospital, who became the first Thai technician to pass the U.S.-based Registered Polysomnographic Technologist (RPSGT) exam.

To further address the shortage of trained personnel, the society launched a “Sleep Technician: Fast Track” program in 2015. This three-month training course includes academic lectures, simulation-based and real patient practice, mentorship from senior sleep technicians, and one-on-one instruction from sleep specialists. The training is conducted across five major institutions: King Chulalongkorn Memorial Hospital, Siriraj Hospital, Ramathibodi Hospital, Phramongkutklao Hospital, and the Central Chest Institute of Thailand.

In 2017, the Mahidol University Council officially recognized the role of sleep technicians as a distinct professional occupation requiring specialized knowledge and skills. This endorsement has helped elevate the status of sleep technicians and increased recognition of the profession within the medical community.

In-Laboratory Sleep Testing

• 64% located in Bangkok
• 56% were situated in private hospitals
• 23% in government hospitals
• 21% in medical schools

The most common reason for referral was suspected obstructive sleep apnea (OSA), with 61% of cases found to have severe sleep-disordered breathing.

The typical cost of a single-night polysomnography test is approximately 10,000 THB. However, the number of facilities offering such services remains limited and insufficient to meet the growing needs of the Thai population. Several provinces still do not have access to polysomnography testing. It is anticipated that the number of sleep laboratories will increase in the future, along with the development of improved screening tools for early identification of sleep disorders.

Recognizing the importance of maintaining standardized quality in sleep diagnostics, the Sleep Society of Thailand initiated a laboratory accreditation program in 2015. As of now, five hospitals have received accreditation: King Chulalongkorn Memorial Hospital, Siriraj Hospital, Ramathibodi Hospital, Phramongkutklao Hospital, and the Central Chest Institute of Thailand.

Public Awareness and Education

Beyond educational booklets such as "100 Sleep Questions Answered" and "All About Snoring", the Sleep Society of Thailand has actively promoted sleep health awareness through various media platforms, including radio, television, newspapers, and the official website: www.sst.or.th.

Since 2012, the society has organized World Sleep Day activities annually. In 2017, the event was held in collaboration with the Department of Health, Ministry of Public Health, reaching 143 locations across the country, including both urban and rural areas. A total of 15,875 participants attended. The activities included public announcements, exhibitions, staff training, community education, and sleep quality assessments using internationally recognized screening tools.

Additionally, Dr. Manoon Leechawengwongs, Chair of the “Drowsiness Behind the Wheel” campaign under the royal patronage of HRH Princess Galyani Vadhana, has consistently promoted public awareness of the dangers of drowsy driving and its role in traffic accidents.

Research

According to data compiled by Assoc. Prof. Dr. Kanit Muntarbhorn at thaisleepindex.com, a total of 220 research studies and academic reports on sleep medicine were published in Thailand between 1980 and 2015, with the majority focusing on obstructive sleep apnea. However, when compared with other Asian countries such as Taiwan and Hong Kong, Thailand still has relatively limited academic output in this field, and significant gaps remain in sleep-related data specific to the Thai population.

Conclusion

The field of sleep medicine in Thailand is expected to continue progressing. While it currently relies on a multidisciplinary model, it is anticipated that the country will eventually have dedicated sleep specialists capable of providing comprehensive care. However, the number of qualified sleep technicians remains insufficient to support the development of this field. It is essential that all sectors collaborate to expand training opportunities for sleep technicians. Moreover, increased local research is needed to generate population-specific data that will guide effective, evidence-based interventions tailored to the Thai population.

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