Download Melatonin for Delayed Sleep Phase Disorder 10092009 (1)

National Public Health Service for Wales
Melatonin for delayed sleep phase disorder
Public health evidence-based summary
Melatonin for delayed sleep phase disorder
Author: Norma Prosser, Public Health Practitioner
Date: 100909
Version: 1
Status: Final
Intended Audience: Public (Internet) / NHS Wales (Intranet) / NPHS (Intranet) /
LHBs
Purpose and Summary of Document:
This paper provides a summary of the evidence regarding melatonin for delayed
sleep phase disorder.
The evidence suggests that the short-term use of melatonin is not effective in treating
most primary sleep disorders, although there is some evidence to suggest that
melatonin is effective in treating delayed sleep phase syndrome with short-term use.
Behavioural and light therapy is the mainstay of treatment for circadian rhythm
disturbances.
Publication/Distribution:

Publication in NPHS Health Social Care Quality Document Database

Link from NPHS e-Bulletin

Link from Stakeholder e-Newsletter
 2009 National Public Health Service for Wales
Author: Norma Prosser, Public Health
Practitioner
Version: 1
Date: 100909
Page: 1 of 5
Status: Final
Intended Audience: Public
(Internet) / NHS Wales (Intranet) /
NPHS (Intranet) / LHBs
National Public Health Service for Wales
1
Melatonin for delayed sleep phase disorder
Purpose
This paper provides a summary of the evidence regarding melatonin for delayed
sleep phase disorder.
2
Introduction
Delayed sleep phase disorder (DSP) or syndrome (DSPS), also called phase lag
syndrome, is a circadian rhythm disorder1. DSP consists of a typical sleep pattern
that is delayed by two or more hours. This delay occurs when ones 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 terms of the amount
and quality of sleep. The delay in the pattern of sleep can be considered undesirable
or socially unacceptable, particularly in regard of waking at the desired time for
normal school, work or social needs2.
Unlike jet lag and the effect of shift work, DSPS is a persistent condition, treatable,
but 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 sleep-wake
patterns. DSPS occurs more frequently in teens and young adults. People who tend
to be night owls, evening types or not morning people are likely to develop DSP2.
Insomnia is classified according to cause3:
 primary, when no comorbidity is identified, the person has conditioned or
learned sleep difficulties, with or without arousal in bed. Typically the insomnia
has a duration of at least 1 month and it accounts for 15-20% of long-term
insomnia;
 secondary or comorbid, when it occurs as a symptom of, or is associated with
other conditions.
Insomnia is also classified by duration or likely duration3:
 short-term, between 1 and 4 weeks;
 long-term or persistent, lasting for 4 weeks or longer.
Symptoms associated with DSP include1, 2:
 individuals reporting 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);
 they do not feel sleepy; symptoms have been present for a least one month;
the syndrome can develop suddenly or gradually.
The medical cause of DSPS is unknown. It can occur in patients who experience
head trauma or serious illness. In these cases, the body’s natural healing process
Author: Norma Prosser, Public Health
Practitioner
Version: 1
Date: 100909
Page: 2 of 5
Status: Final
Intended Audience: Public
(Internet) / NHS Wales (Intranet) /
NPHS (Intranet) / LHBs
National Public Health Service for Wales
Melatonin for delayed sleep phase disorder
may disrupt normal circadian rhythm and render the biological clock unable to resent
or resynchronise4.
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 therapy4.
Sleep hygiene
Sleep hygiene practice include: limiting large meals; 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 times1, 4.
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 light1, 5.
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.
Chronotherapy can interfere with prescription medications and indications associated
with other disorders e.g. those on insulin or who have immune system disorders 1, 5.
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 1.
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 ingredients6.
3
Evidence summary
The American Agency for Healthcare Research and Quality (AHRQ)6 in a systematic
review of melatonin for the treatment of sleep disorders conclude that the evidence
suggests that melatonin is:


not effective in treating most primary sleep disorders with short-term use,
although some evidence suggests that melatonin is effective in treating
delayed sleep phase syndrome with short-term use;
not effective in treating most secondary disorders with short-term use;
Author: Norma Prosser, Public Health
Practitioner
Version: 1
Date: 100909
Page: 3 of 5
Status: Final
Intended Audience: Public
(Internet) / NHS Wales (Intranet) /
NPHS (Intranet) / LHBs
National Public Health Service for Wales


Melatonin for delayed sleep phase disorder
not effective in alleviating the sleep disturbance aspect of jet lag and shift-work
disorder;
safe with short-term use.
A recent systematic review of the effectiveness of oral melatonin for adults (18 to 65
years) with DSPS and adults (18 to 65 years) with primary insomnia (PI) has
concluded that there is limited support for its use in people with DSPS, and little
evidence to support its use for PI7.
The American online text book eMedicine5 report:
“Behavioural and light therapy are the mainstays of circadian rhythm disturbances.
Emphasize good sleep hygiene and discourage maladaptive behaviours”.
CKS (NHS Clinical Knowledge Summaries)3 in a recent review of insomnia (July
2009), report that melatonin for primary insomnia:
“At the dose and duration of modified-release melatonin licensed for use in the UK,
two randomized controlled trials (RCTs) reported an improvement in the quality of
sleep and morning alertness, although the clinical significance of the improvement is
unclear. In one of the studies, a small improvement in sleep-onset latency (time taken
to get to sleep) was also noted with melatonin. CKS identified no studies comparing
modified-release melatonin with hypnotics for the treatment of insomnia”.
4
Conclusion
The 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.
Behavioural and light therapy is the mainstay of treatment for circadian rhythm
disturbances.
5
Review
The public health evidence summary will be reviewed in three years, or earlier, if
circumstances necessitate an earlier review.
6
References
1. sleepchannel. Delayed sleep phase syndrome [online]. Available at:
http://www.sleepdisorderchannel.com/dsps/index.shtml [Accessed 17th
Apr 2009]
2. American Academy of Sleep Medicine. Sleepeducation.com. Delayed
sleep phase [online]. Available at:
http://www.sleepeducation.com/Disorder.aspx?id=30 [Accessed 17th Apr
2009]
3. CKS. Insomnia [online]. 2009. Available at:
http://www.cks.nhs.uk/insomnia [Accessed 8th Sep 2009]
Author: Norma Prosser, Public Health
Practitioner
Version: 1
Date: 100909
Page: 4 of 5
Status: Final
Intended Audience: Public
(Internet) / NHS Wales (Intranet) /
NPHS (Intranet) / LHBs
National Public Health Service for Wales
Melatonin for delayed sleep phase disorder
4. Cleveland Clinic. Delayed sleep phase syndrome and advanced sleep
phase syndrome [online]. Available at:
http://my.clevelandclinic.org/disorders/Circadian_Rhythm_Disorders/hic_D
elayed_Sleep_Phase_Syndrome_and_Advanced_Sleep_Phase_Syndrom
e.aspx [Accessed 17th Apr 2009]
5. eMedicine. Sleeplessness and circadian rhythm disorder [online]. Available
at: http://emedicine.medscape.com/article/1188944-overview [Accessed
17th Apr 2009]]
6. Buscemi M et al. Melatonin for treatment of sleep disorders. Evidence
Report/Technology Assessment No. 108. AHRQ Publication No. 05-E002.
Rockville: Agency for Healthcare Research and Quality; 2004. Available at:
http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat1a.chapter.74599
[Accessed 15th Apr 2009]
7. MacMahon KM, Broomfield NM, Espie CA. A systematic review of the
effectiveness of oral melatonin for adults (18 to 65 years) with delayed
sleep phase syndrome and adults (18 to 65 years) with primary insomnia.
Database of Abstracts of Reviews of Effects (DARE). 2005. Available at:
http://www.mrw.interscience.wiley.com/cochrane/cldare/articles/DARE12006006046/frame.html [Accessed 15th Apr 2009]
Author: Norma Prosser, Public Health
Practitioner
Version: 1
Date: 100909
Page: 5 of 5
Status: Final
Intended Audience: Public
(Internet) / NHS Wales (Intranet) /
NPHS (Intranet) / LHBs