Evidence-Based Reviews

‘Night owls’: Reset the physiologic clock in delayed sleep phase disorder

Current Psychiatry. 2009 March;8(3):55-65

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Other options

Hypnotics. Little evidence supports the use of hypnotics in DSPD,³² and patients may show resistance to these drugs.³³ Nevertheless, hypnotics can heighten confidence in the ability to initiate sleep in individuals with a concomitant conditioned insomnia.

With chronotherapy, patients are prescribed a sleep schedule that is delayed several hours incrementally until sleep is aligned to a target bedtime. The individual then is advised to rigorously maintain a regular sleep/wake schedule, repeating the process as necessary.

Although case reports have shown positive results with chronotherapy for DSPD,³⁴ no controlled trials have demonstrated its efficacy or safety. One study reported high relapse rates,³¹ and 1 patient with DSPD developed free-running circadian rhythms.³⁵ Clinical experience suggests chronotherapy is impractical for patients who must adhere to a fixed schedule.

Behavioral approaches

For an adolescent with DSPD, consider asking the school district to allow him or her a later school start-time. This alone often can substantially increase total sleep time and mitigate associated impairments.³⁶ In all instances pursue and address external contributors to DSPD, such as poor sleep hygiene (including excessive caffeine use) and substance misuse.

Emphasize regular wake times, as arising later on weekends can cause phase delays.³⁷ DSPD patients may have a concomitant conditioned insomnia that responds to evidence-based behavioral treatments.³⁸

Clinical Point

Emphasize regular wake times, as arising later on weekends can cause sleep phase delays

Whatever intervention you choose, schedule a follow-up appointment in approximately 2 months to evaluate patients’ progress and compliance. Encourage them to contact you with questions or concerns in the interim. Review sleep logs or actigraphy during this visit, and adjust the timing and/or nature of interventions as needed. Adolescents can be particularly noncompliant with clinical interventions, and therapeutic goals cannot be reached without their full investment.

Because no guidelines exist on how long to treat DSPD, stop on a “trial-and-error” basis when symptoms are controlled, and resume if they recur. Another approach is to maintain a desired sleep/wake schedule with bedtime melatonin and encourage continued adherence to other measures.

CASE CONTINUED: Maintenance therapy

Jason returns to the clinic approximately 10 weeks later. After an obviously concerted effort to adhere to treatment, his progress is quite remarkable. He rarely falls asleep later than 11 PM, so he is obtaining 2.5 hours more sleep each night before arising for school at 6:30 AM. Sleepiness at school is rarely problematic, and his mood is more stable.

Clinical Point

Address external contributors to DSPD, such as poor sleep hygiene, excessive caffeine use, and substance misuse

He nevertheless describes a persistent tendency to retire and arise later and asks to continue melatonin and phototherapy. Because no guidelines exist for long-term therapy of DSPD, he is advised to switch melatonin to bedtime dosing (with a presumed phase-neutral “maintenance” effect), and to continue phototherapy as prescribed.

Related resources

Wyatt JK. Delayed sleep phase syndrome: pathophysiology and treatment options. Sleep. 2004;27(6):1195-1203.
Crowley SJ, Acebo C, Carskadon MA. Sleep, circadian rhythms, and delayed sleep phase in adolescence. Sleep Med. 2007;8(6):602-612.
National Sleep Foundation. Adolescent sleep needs and patterns: research report and resource guide. Washington, DC; 2000:1-30.
Products designed to assist in the avoidance of light at improper times. www.lowbluelights.com.

Disclosure

Dr. Auger reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.