Download Melatonin for Delayed Sleep Phase Disorder

PUBLIC HEALTH ADVICE - 16
MELATONIN FOR DELAYED SLEEP PHASE DISORDER
DELAYED SLEEP PHASE DISORDER
Delayed sleep phase disorder (DSP) or syndrome (DSPS), also called phase lag
syndrome, is a circadian rhythm disorder.
DSP consists of a typical sleep pattern that is “delayed” by two or more hours. This
delay occurs when one’s internal biological sleep clock (circadian rhythm) is shifted
later at night and hence later into the morning. Once sleep occurs, the sleep is
generally normal, in respect of the amount and quality of sleep. The delay in the
pattern of sleep can be considered undesirable or socially unacceptable, particularly
in terms of waking at the desired time for normal school, work or social needs.
Unlike jet lag and the effect of shift work, DSPS is a persistent condition, treatable,
but it is reported not curable. DSPS is often mistaken for other types of insomnia. In
clinical settings, it is reported as one of the most common complications of sleepwake patterns.
DSPS occurs more frequently in teens and young adults. People who tend to be
“night owls”, “evening types” or “not being morning people” are likely to develop DSP.
MAIN SYMPTOMS OF DSP

DSPS causes sleep-onset insomnia. Often, DSP individuals report that they
cannot sleep until early morning. Unlike most other insomniacs, no matter
what time they go to bed, they fall asleep at about the same time every night,
and sleep comes quite rapidly.

Unless there are other untreated sleep disorders in addition to DSPS,
individuals have a normal need for sleep, can sleep well, and wake up
spontaneously, if allowed to follow their own sleep schedule e.g. 4 a.m. to
noon, and they do not feel sleepy.
Author: NP
Filename: Melatonin for delayed sleep
Review Date: July 2009
Page 1 of 4
Status: Final
Version: 1
Date: 17 July 2006

Symptoms have been present for a least one month.

The syndrome can develop suddenly or gradually.
CAUSES
The medical cause of DSPS is unknown. Circadian rhythms which regulate the
internal, biological clock and influence functions, such as sleep-wake patterns are
usually described as being out-of-phase in DSPS.
DSPS often occurs in patients who experience head trauma or serious illness. In
these cases, the body’s natural healing process may disrupt normal circadian rhythm
and render the biological clock unable to resent or resynchronise.
TREATMENT OF DSPS
DSPS treatments are meant to adjust a persons’ circadian rhythm and sleep pattern
to fit into a schedule of the individuals’ desired lifestyle.
Since the ability to wake up and function normally depends on an adequate amount
of sleep, the patient gradually adjusts to an earlier bedtime. Sleep therapy usually
combines sleep hygiene practice and external stimulus therapy.
Sleep Hygiene
Sleep hygiene practice include:
 Avoiding caffeine, alcohol and tobacco;
 Exercising in the early part of the day as opposed to the evening;
 Practising stress reduction techniques;
 Making slight variations in sleep and wake times.
Bright light therapy
Early morning exposure to light tends to lead to an early wake time and advance
sleep onset at night. Artificial light is often used especially early in the morning and in
the winter months to expose patients to bright light. A light box is often used to emit a
standard dosage of white light.
Chronotherapy
This treatment is used to manipulate the sleep-wake cycle in an attempt to change
the patient’s underlying circadian rhythm. The patient progressively goes to bed and
wakes up 3 hours later than the previous night, until over a period of time their sleep
pattern have moved around the clock and into an acceptable sleep schedule.
Author: NP
Filename: Melatonin for delayed sleep
Review Date: July 2009
Page 2 of 4
Status: Final
Version: 1
Date: 17 July 2006
Chronotherapy can interfere with prescription medications and indications associated
with other disorders e.g. those on insulin or who have immune system disorders.
Melatonin
Melatonin is a natural hormone that is produced primarily by the pineal gland in the
brain when the body prepares for sleep. Secretion occurs when it becomes dark and
is suppressed by exposure to light. Melatonin secretion is also associated with diet.
Two forms of melatonin is produced; animal or bovine grade containing the actual
extracts of the pineal gland. Synthetic or pharmacy grade produced from
pharmaceutical grade ingredients.
MELATONIN FOR DELAYED SLEEP PHASE DISORDER
A review of the evidence of melatonin for delayed sleep phase disorder was
undertaken by the National Library for Health (NLH), Primary Care Question
Answering Service in April 2006, in response to the questions:
“What information is there on delayed sleep phase syndrome. I have a patient whose
sleep pattern is delayed by half an hour every day, it seems to b e dysfunction of the
circadian rhythm? Is melatonin effective? What treatment options?”1
The following is taken from the answer published by NLH.
With regard to DSPS, an American online textbook, has a section on DSPS 2 and
offers the following summary:
“Behavioural and light therapy are the mainstays of circadian rhythm disturbances.
Emphasize good sleep hygiene and discourage maladaptive behaviours”.
With regard to melatonin the American Agency for Healthcare Research and Quality
published a systematic review of melatonin in sleep disorders (Summary3, Full
report4). With regard to delayed sleep-phase syndrome it reported:
“Melatonin decreased sleep onset latency greatly in people with delayed phase
syndrome …… The magnitude if this effect appears to be clinically significant”.
Later in the discussion it further comments on the significance of melatonin:
“Indeed, the magnitude of the effects of melatonin appear to be of no clinical
significance in the populations studied in this review, except for people suffering from
delayed sleep phase syndrome. However, even for the latter population, one cannot
definitively conclude that melatonin is effective in alleviating the sleep disturbance,
since the observation of melatonin effectiveness in this population was based on only
two studies with less than 25 participants”.
Author: NP
Filename: Melatonin for delayed sleep
Review Date: July 2009
Page 3 of 4
Status: Final
Version: 1
Date: 17 July 2006
It later concludes:
“Evidence suggests that melatonin is not effective in treating most primary sleep
disorders with short-term use, although there is some evidence to suggest that
melatonin is effective in treating delayed sleep phase syndrome with short-term use”.
CONCLUSION
Lifestyles that allow alternative sleep-wake patterns e.g. work-at-home jobs,
computer programming, artistic careers may help sustain DSPS, rather than to shape
the disorder.
The evidence from the review undertaken by the NLH suggests that melatonin is not
effective in treating most primary sleep disorders with short-term use, although there
is some evidence to suggest that melatonin is effective in treating delayed sleep
phase syndrome with short-term use.
REVIEW
This health policy advice will be reviewed in three years November 2008, or earlier if
any circumstances initiate a review.
References:
1. Primary Care Question Answering Service NHS
http://www.clinicalanswers.nhs.uk/index.cfm?question=2736
2. Medicine. Sleeplessness and Circadian Rhythm Disorder. 2005
http://www.emedicine.com/neuro/topic655.htm
3. AHRQ. Melatonin for Treatment of Sleep Disorders. 2004
http://www.ahcpr.gov/clinic/epcsums/melatsum.htm
4. Melatonin for Treatment of Sleep Disorders
PDF File (1.6
MB)http://www.ahrq.gov/downloads/pub/evidence/pdf/melatonin/melatonin.pdf
Author: NP
Filename: Melatonin for delayed sleep
Review Date: July 2009
Page 4 of 4
Status: Final
Version: 1
Date: 17 July 2006