The treatment plan for the patient’s Delayed Sleep-Wake Phase Disorder (DSWPD) is based on clinical guidelines published by the American Academy of Sleep Medicine in 2007 (Practice Parameters for the Clinical Evaluation and Treatment of Circadian Rhythm Sleep Disorders) and the published research since that time. The 2007 guidelines stated the following: (1) Morning light exposure is indicated (Guideline); (2) Properly timed melatonin administration is indicated (Guideline); and (3) Chronotherapy (i.e., prescribed progressive changes in the schedule of sleep time until the desired sleep schedule is reached) may be useful (Option).
Delayed Sleep Wake Phase Disorder
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American Academy of Sleep Medicine: Practice Parameters for the Clinical Evaluation and Treatment of Circadian Rhythm Sleep Disorders. (2007). [PDF]
3.2.4.2 Morning light exposure is indicated in the treatment of DSPD. Optimal timing, duration, and dosing of morning light treatment for DSPD remain to be determined. [12.4.2] (Guideline)
One level 1 [80] and one level 2 [81] study demonstrated that properly timed morning light exposure causes a phase advance of sleep onset time and circadian rhythms (CBTmin), and increases objectively determined daytime alertness. In the reviewed studies, 2500 lux for 2-3 hours prior to or at rise time was used. The effects of lower doses, blue light wavelengths, or other timings are not yet known. The treatments were generally well tolerated and of some beneficial effect, but more potent and less difficult to follow treatments are needed.
80. Cole, RJ, Smith, JS, Alcala, YC, Elliott, JA, and Kripke, DF. Brightlight mask treatment of delayed sleep phase syndrome. Journal of Biological Rhythms 2002;17:89-101.
81. Rosenthal, NE, Joseph-Vanderpool, JR, Levendosky, AA, et al. Phase-shifting effects of bright morning light as treatment for delayed sleep phase syndrome. Sleep 1990;13:354-361.
3.2.4.3. Chronotherapy (i.e., prescribed progressive delay in the schedule of sleep time until the desired sleep schedule is reached) may be useful for DSPD. [12.4.1] (Option)
This recommendation for chronotherapy is based only on two level 4 case report studies [82, 83] and committee consensus; there are no controlled trials supporting its efficacy or safety. Longer lasting and more practical alternatives are needed given that compliance with the treatment is difficult and lasting benefit has not been demonstrated.
3.2.4.4 Properly timed melatonin administration is indicated as a therapy for DSPD. [12.4.3] (Guideline)
This recommendation is supported by one level 1 [84] two level 2 [85, 86] and one level 4 [87] studies. Afternoon or evening administration of melatonin shifts circadian rhythms (indicated by dim light melatonin onset [DLMO] and core body temperature minimum, [CBTmin]) to an earlier time. Compared to placebo, melatonin treatment reduced sleep onset latency, but there was no change in total sleep time or subjective daytime alertness. As with other studies involving melatonin, the optimal timing and dosing of melatonin administration are not established. In the reviewed studies, three used 5 mg [84, 85, 87] while one [86] used two strengths (0.3 mg and 3 mg). Effective times of administration varied between 1.5 and 6 hours prior to the habitual bedtime.
84. Kayumov, L, Brown, G, Jindal, R, Buttoo, K, and Shapiro, CM. A randomized, double-blind, placebo-controlled crossover study of the effect of exogenous melatonin on delayed sleep phase syndrome. Psychosomatic medicine 2001;63:40-48. https://www.ncbi.nlm.nih.gov/pubmed/11211063
85. Dahlitz, M, Alvarez, B, Vignau, J, English, J, Arendt, J, and Parkes, JD. Delayed sleep phase syndrome response to melatonin. Lancet 1991;337:1121-1124.
86. Mundey, K, Benloucif, S, Harsanyi, K, Dubocovich, ML, and Zee, PC. Phase-dependent treatment of delayed sleep phase syndrome with melatonin. Sleep 2005;28:1271-1278. https://www.ncbi.nlm.nih.gov/pubmed/16295212
87. Dagan, Y, Yovel, I, Hallis, D, Eisenstein, M, and Raichik, I. Evaluating the role of melatonin in the long-term treatment of delayed sleep phase syndrome (DSPS). Chronobiology International 1998;15:181-190.
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American Academy of Sleep Medicine Review: Circadian Rhythm Sleep Disorders: Part II, Advanced Sleep Phase Disorder, Delayed Sleep Phase Disorder, Free-Running Disorder, and Irregular Sleep-Wake Rhythm (2007)
12.4.2 Timed Light Exposure
Light exposure in the morning, on the advance portion of the light PRC, would be expected to shift circadian rhythms earlier, thereby correcting a pathological phase delay. Rosenthal et al. (level 2) [46] treated 20 patients diagnosed with DSPD for two weeks using two hours of bright light exposure (2,500 lux) and two hours of ordinary light (300 lux) exposure in the morning (between 06:00 and 09:00) in a crossover design. The bright light treatment produced a significant phase advance of the core body temperature rhythm, although there was no attempt to minimize masking, as well as an increase in morning alertness as measured with the MSLT.
In a novel study, Cole, et al. (level 1) [47] treated DSPD with an illuminated mask that provided light through closed eyelids during sleep. The light mask was reported as well tolerated, producing little sleep disturbance. The mask turned on (<0.01 lux) four hours before arising, ramped up for one hour, and remained on at full brightness until arising (2500 lux for active treatment, 0.1 lux for controls). The bright light treatment advanced the timing of aMT6s by one hour after 26 days of treatment, and advanced sleep onset times in the subset of patients with the most delayed phases.
Conclusion: Although the evidence is limited, light exposure treatment, timed to advance rhythms based on the light PRC, appears to be a rational and effective intervention for DSPD. In the clinical context, compliance may be a significant problem.
12.4.3 Timed Melatonin Administration
Melatonin administration in the afternoon or evening, during the phase advance portion of the melatonin PRC, would be expected to shift rhythms earlier, thereby correcting a pathological phase delay. This hypothesis was supported in an early study of limited sample size (N = 8), (level 2) [48]. In a large (N = 61), open-label study, those receiving 5 mg of melatonin given at 22:00 for six weeks reported significant benefit, but also a high rate of relapse when treatment was discontinued (level 4) [49].
In a double-blind, cross-over study, DSPD patients (N = 20) were treated with 5 mg melatonin or placebo, taken between 19:00 and 21:00 (time chosen by each patient) for four weeks (level 1) [50]. Two consecutive PSGs were performed during an imposed sleep schedule (24:00 to 08:00) on three occasions: at baseline (before treatment), then after each arm of treatment. Melatonin treatment led to normalization in the rhythm of aMT6s excretion compared to placebo, and significantly reduced sleep onset latency as determined by PSG. However, PSG-determined TST was not increased, nor were self-reported measures of daytime alertness improved.
A recent double-blind study tested two doses of melatonin (0.3 and 3 mg) vs. placebo (level 2) [41]. Circadian phase using DLMO and core body temperature minimum (CBTmin.) was measured before and after treatment. Treatment was administered between 1.5 and 6.5 hours prior to the DLMO for four weeks. Both doses advanced DLMO and CBTmin; the earlier the melatonin was administered relative to DLMO, the larger the phase advance, consistent with the reported melatonin PRC [51].
Conclusion: The evidence is quite strong that melatonin, timed to promote a corrective phase advance, is an effective treatment for DSPD. Determining the optimal parameters for scheduling and dosing will require more study.
Auger RR, Burgess HJ, Emens JS, Deriy LV,
Thomas SM, Sharkey KM. Clinical practice guideline for the
treatment of intrinsic circadian rhythm sleep-wake disorders:
advanced sleep-wake phase disorder (ASWPD), delayed
sleep-wake phase disorder (DSWPD), non-24-hour sleepwake
rhythm disorder (N24SWD), and irregular sleep-wake
rhythm disorder (ISWRD). An update for 2015. J Clin Sleep
Med 2015;11(10):1199 –1236 .
The present document replaces/updates the previous American
Academy of Sleep Medicine (AASM) Practice Parameters
pertaining to the intrinsic CRSWDs (i.e., ASWPD, DSWPD,
N24SWD, and ISWRD). The treatment of remaining CRSWDs
is not addressed.
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Recommendations are as Follows
ASWPD
5.1.4a The TF suggests that clinicians treat adult ASWPD
patients with evening light therapy (versus no treatment).
[WEAK FOR]
DSWPD
5.2.6.1a The TF suggests that clinicians treat DSWPD in
adults with and without depression with strategically timed
melatonin (versus no treatment). [WEAK FOR]
5.2.6.2.1a The TF suggests that clinicians treat children
and adolescents with DSWPD (and no comorbidities) with
strategically timed melatonin (versus no treatment). [WEAK
FOR]
5.2.6.2.2a The TF suggests that clinicians treat children
and adolescents with DSWPD comorbid with psychiatric
conditions with strategically timed melatonin (versus no
treatment). [WEAK FOR]
5.2.9.2a The TF suggests that clinicians treat children
and adolescents with DSWPD with post-awakening light
therapy in conjunction with behavioral treatments (versus no
treatment). [WEAK FOR]
N24SWD
5.3.6.1a The TF suggests that clinicians use strategically
timed melatonin for the treatment of N24SWD in blind adults
(versus no treatment). [WEAK FOR]
ISWRD
5.4.4a The TF suggests that clinicians treat ISWRD in
elderly patients with dementia with light therapy (versus no
treatment). [WEAK FOR]
5.4.5a The TF recommends that clinicians avoid the use
of sleep-promoting medications to treat demented elderly
patients with ISWRD (versus no treatment). [STRONG
AGAINST]
5.4.6.1a The TF suggests that clinicians avoid the use of
melatonin as a treatment for ISWRD in older people with
dementia (versus no treatment). [WEAK AGAINST]
5.4.6.2a The TF suggests that clinicians use strategically
timed melatonin as a treatment for ISWRD in children/
adolescents with neurologic disorders (versus no treatment).
[WEAK FOR]
5.4.9.1a The TF suggests that clinicians avoid the use
of combined treatments consisting of light therapy in
combination with melatonin in demented, elderly patients
with ISWRD (versus no treatment). [WEAK AGAINST]
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* Although no randomized controlled trials have examined sleep-promoting medications for the treatment of ISWRD, other extant literature indicates that
administration of hypnotics to demented elderly patients increases risks of falls and other untoward outcomes (see separate “Harms and Adverse Effects”
section).
The purpose of the present
publication is to provide an evidence-based update of existing
recommendations for the treatment of the intrinsic CRSWDs:
advanced sleep-wake phase disorder (ASWPD), delayed sleepwake
phase disorder (DSWPD), non-24-hour sleep-wake
rhythm disorder (N24SWD), and irregular sleep-wake rhythm
disorder (ISWRD). The extrinsic or predominantly environmentally
influenced CRSWDs, namely shift work and jet lag
disorder, are not addressed in this paper.
DSWPD manifests as a delay of the major sleep episode with
respect to the patient’s desired timing or the timing required to
attend to social, educational, and/or occupational demands.
Finally, although commercially available products do not
emit ultraviolet light, patients with eye disease and/or those
using photosensitizing medications should only use light
therapy with periodic ophthalmological and/or dermatological
monitoring of the underlying condition.40,42,43 Reassuringly,
one study reported no changes in extensive ophthalmologic examinations
among seasonal affective disorder patients without
preexisting conditions after up to 6 years of daily use in the fall
and winter months.42