Delayed Sleep Phase Disorder - Management

Management

Treatment, a set of management techniques, is specific to DSPD. It is different from treatment of insomnia, and recognizes the patients' ability to sleep well on their own schedules, while addressing the timing problem. Success, if any, may be partial; for example, a patient who normally awakens at noon may only attain a wake time of 10 or 10:30 with treatment and follow-up. Being consistent with the treatment is paramount.

Before starting DSPD treatment, patients are often asked to spend at least a week sleeping regularly, without napping, at the times when the patient is most comfortable. It is important for patients to start treatment well-rested.

Treatments that have been reported in the medical literature include:

Light therapy (phototherapy) with a full spectrum lamp or portable visor, usually 10,000 lux for 30–90 minutes at the patient's usual time of spontaneous awakening, or shortly before (but not long before), which is in accordance with the phase response curve (PRC) for light. The use of an LED light therapy device can reduce this to 15–30 minutes. Sunlight can also be used. Only experimentation, preferably with specialist help, will show how great an advance is possible and comfortable. For maintenance, some patients must continue the treatment indefinitely, some may reduce the daily treatment to 15 minutes, others may use the lamp, for example, just a few days a week or just every third week. Whether the treatment is successful is highly individual. Light therapy generally requires adding some extra time to the patient's morning routine. Patients with a family history of macular degeneration are advised to consult with an eye doctor. The use of exogenous melatonin administration (see below) in conjunction with light therapy is common.

Light restriction in the evening, sometimes called darkness therapy. Just as bright light upon awakening should advance one's sleep-phase, bright light in the evening and night delays it (see the PRC). It is suspected that DSPS patients may be overly sensitive to evening light. Thus, one might be advised to keep lights dim the last hours before bedtime and even wear sunglasses or amber-colored (blue-blocking) goggles. The photopigment of the retinal photosensitive ganglion cells, melanopsin, is excited by light mainly in the blue portion of the visible spectrum (absorption peaks at ~480 nanometers).

Attaining an earlier sleep onset, in a dark room with eyes closed, effectively blocks a period of phase-delaying light. An understanding of this is a motivating factor in treatment.

Chronotherapy, which is intended to reset the circadian clock by manipulating bedtimes. Often, chronotherapy must be repeated every few months to maintain results, and its safety is uncertain. It can be one of two types. The most common consists of going to bed two or more hours later each day for several days until the desired bedtime is reached. A modified chronotherapy (Thorpy, 1988) is called controlled sleep deprivation with phase advance, SDPA. One stays awake one whole night and day, then goes to bed 90 minutes earlier than usual and maintains the new bedtime for a week. This process is repeated weekly until the desired bedtime is reached.

Melatonin taken an hour or so before usual bedtime may induce sleepiness.

Taken this late, it does not, of itself, affect circadian rhythms, but a decrease in exposure to light in the evening is helpful in establishing an earlier pattern. In accordance with its phase response curve (PRC), a very small dose of melatonin can also, or instead, be taken some hours earlier as an aid to resetting the body clock; it must then be so small as to not induce excessive sleepiness.

Side effects of melatonin may include disturbance of sleep, nightmares, daytime sleepiness and depression, though the current tendency to use lower doses has decreased such complaints. Large doses of melatonin can even be counterproductive: Lewy et al. provide support to the "idea that too much melatonin may spill over onto the wrong zone of the melatonin phase-response curve." The long-term effects of melatonin administration have not been examined. In some countries the hormone is available only by prescription or not at all. In the United States and Canada, melatonin is freely available as a dietary supplement. The prescription drug Rozerem (ramelteon) is a melatonin analogue that selectively binds to the melatonin MT₁ and MT₂ receptors and, hence, has the possibility of being effective in the treatment of DSPD.

A review by a US government agency found little difference between melatonin and placebo for most primary and secondary sleep disorders. The one exception, where melatonin is effective, is the "circadian abnormality" DSPD.

Cannabis has been suggested as an aid to combat DSPD. However, no research has yet been done that shows cannabis works in DSPD. Sleep onset is affected by the two primary cannabinoids. THC, Δ9-Tetrahydrocannabinol, dramatically increased melatonin production in some subjects in a small study in 1986 where the authors state that "hese preliminary results are difficult to interpret". An older study showed that CBD, cannabidiol, was effective in helping insomniacs sleep. Several studies have shown that acute administration of THC decreases sleep latency, and is associated with reports of greater ease in getting to sleep. Heavy cannabis use can lead to decreased levels of REM sleep and increased levels of slow-wave sleep along with reduced mental function the next morning; however, 5 mg doses of THC and CBD have been shown not to have these effects.

Modafinil (Provigil) is approved in the US for treatment of shift-work sleep disorder, which shares some characteristics with DSPD. A number of clinicians are prescribing it for DSPS patients as it may improve a sleep-deprived patient's quality of life. Taking modafinil less than 12 hours before the desired sleep onset time will likely exacerbate the symptoms by delaying sleep.

Trazodone successfully treated DSPD in one elderly man.

Vitamin B₁₂ was, in the 1990s, suggested as a remedy for DSPD, and can still be found to be recommended by many sources. Several case reports were published. However, a review for the American Academy of Sleep Medicine in 2007 concluded that no benefit was seen from this treatment.

A strict schedule and good sleep hygiene are essential in maintaining any good effects of treatment. With treatment, some people with mild DSPD may sleep and function well with an early sleep schedule. Caffeine and other stimulant drugs to keep a person awake during the day may not be necessary, and should be avoided in the afternoon and evening, in accordance with good sleep hygiene. A chief difficulty of treating DSPD is in maintaining an earlier schedule after it has been established. Inevitable events of normal life, such as staying up late for a celebration or having to stay in bed with an illness, tend to reset the sleeping schedule to its intrinsic late times.