To correct the delayed sleep phase, we can use the two factors that are key to regulating the circadian rhythm in humans—melatonin and light. We can combine them in what I call a “pull from both ends” approach. What I mean is that melatonin in the evening will pull the sleep phase towards an earlier bedtime and light exposure early in the morning will do the same.
In all of us, dim light in the evenings leads to a natural and gradual rise in melatonin levels, which is called Dim Light Melatonin Onset or DLMO. This DLMO typically occurs between 730 pm and 930 pm in adults and a little earlier in children. This DLMO is delayed in many patients with Delayed Sleep Phase Disorder.
A meta-analysis of studies of the use of melatonin to treat Delayed Sleep Phase Disorder (van Geijlswijk et al., 2010) found that it was effective in both children and adults. It helped both the DLMO and onset of sleep to occur earlier compared to persons who received placebo.
We have to get the timing right
When should the melatonin be given to advance the sleep phase, i.e., to move it towards an earlier bedtime? For the greatest efficacy in advancing the sleep phase towards an earlier bedtime, melatonin should be given about five hours prior to DLMO (van Geijlswijk et al., 2010). But, the problem is that in patients with DSPD, we don’t know when their DLMO is occurring. So, some trial and error will be needed. But, as a start, melatonin should be given about five hours prior to when the person typically sleeps at this time, i.e., on the delayed schedule. This can be estimated before starting treatment and during it by asking the patient to keep careful sleep logs or using an actigraphy device.
More is not always better
When using melatonin for Delayed Sleep Phase Disorder, to the best of our knowledge, 0.3 mg to 0.5 mg is the optimal starting dose.
Firstly, it may be as effective as higher doses (Mundey et al., 2005; Burgess et al., 2010). Secondly, if very high doses are used, instead of getting the phase-shifting benefit, the person may become sleepy.
Pulling at the other end: Bright light therapy in the morning
To shift the sleep phase in persons with Delayed Sleep Phase Disorder, along with low dose melatonin in the evening, bright light therapy in the morning is recommended. Just like the timing of giving melatonin, the timing of bright light therapy is also very important. It should be given as soon as possible after the person wakes up.
Warning! What we are trying to do is to give bright light therapy right after the person’s core body temperature (a key measure of the circadian rhythm) is at its minimum. Since we can’t monitor core body temperature outside of research settings, we recommend doing bright light therapy immediately after waking up. But, if, for some reason, the person wakes up much earlier than usual, bright light therapy should not be done at that time; it may cause the sleep phase to shift in the wrong direction (Lovato et al., 2016). Similarly, if the person sleeps till the afternoon (not rare in my patients who are college students!), bright light therapy given at that time may not result in phase advance (Lovato et al., 2016).
In one clinical trial, bright white light therapy at 10,000 lux (same as what is recommended for mood disorder) for 30 to 45 minutes immediately after waking up led to improvements in the time the person when to sleep, how long it took to fall asleep, and how alert the person felt the next day; the benefits were sustained over three months of follow up (Saxvig et al., 2014).
Reduce light exposure in the evening
Patients with Delayed Sleep Phase Disorder may be hypersensitive to light exposure in the evening. So, even more than everyone else, they need to reduce light exposure in the evening. This can be done by turning off lights as much as possible, avoiding or reducing exposure to screens (computer, tablet, smartphone, TV) in the evening, using the free software f.lux (available at https://justgetflux.com), and so on. We’ll discuss these strategies in greater detail on another page on this website.
Combining melatonin and bright white light therapy
One may hypothesize that the combination of low dose melatonin in the evening and bright white light therapy in the morning might be more efficacious than either alone. One paper recommended starting with bright white light and adding melatonin later if that does not work (Bjorvatn and Pallesen, 2009). But, in my experience, adherence to bright white light therapy is a struggle, especially in my patients with ADHD who are the ones who have Delayed Sleep Phase Disorder. So, my own practice is to recommend low dose melatonin and bright white light therapy simultaneously.
When melatonin and bright light therapy are used together, typically the melatonin should be given 12 hours before and after the bright white light therapy (Bjorvatn and Pallesen, 2009).
Move backwards gradually
It has been suggested that when using melatonin to try to shift the phase to earlier, we should gradually change the time of taking melatonin earlier and earlier, moving backward gradually (Bjorvatn and Pallesen, 2009; van Geijlswijk et al., 2010).
Similarly, bright light therapy in the morning should be given earlier and earlier, changing by anywhere between 15 to 60 minutes at a time until the person is waking up at the desired time (Lack and Wright, 2007).
Are we going in the right direction?
We should accept that without formal testing of DLMO or core body temperature patterns, both of which are not easy to do in clinical practice, we can’t really be completely sure what the circadian rhythm is in a particular person. We can estimate it based on sleep patterns when the person is allowed to sleep in whatever way s/he pleases, but it is still only an estimate.
If we combine his humility with the point above that the timing of bright white light in relation to the person’s circadian rhythm will determine whether the treatment leads to phase advance, no change, or worsening of the phase delay, we realize that we should keep an open mind. The person should be told to monitor whether or not it is becoming a bit easier to go bed earlier and wake up earlier. If not, and especially if the problem is worsening, we should consider the possibility that we have misjudged the person’s circadian rhythm and adjust the timing of our interventions accordingly (Bjorvatn and Pallesen, 2009). In such situations, it should strongly consider getting a consultation with a sleep disorders specialist.
How long does the treatment need to be continued?
When I recommend low-dose melatonin in the evening plus bright white light therapy in the morning to my patients who have Delayed Sleep Phase Disorder, they sometimes ask the natural question: How long should I continue taking the melatonin and the bright white light therapy?
The answer to that is, unfortunately, that when melatonin is stopped in patients with Delayed Sleep Phase Disorder, the person is likely to return to the previous sleep pattern (Dagan et al., 1998). This may take a few days or several months.
The same is true in general for bright white light therapy for Delayed Sleep Phase Disorder. But, after initial daily treatment for a few weeks, some patients may be able to maintain their improved sleep phase by doing bright white light therapy only two to four days a week (Bjorvatn and Pallesen, 2009).
Reviews and meta-analyses
Bjorvatn B, Pallesen S. A practical approach to circadian rhythm sleep disorders. Sleep Med Rev. 2009 Feb;13(1):47-60. Review. PubMed PMID: 18845459.
van Geijlswijk IM, Korzilius HP, Smits MG. The use of exogenous melatonin in delayed sleep phase disorder: a meta-analysis. Sleep. 2010 Dec;33(12):1605-14. Review. PubMed PMID: 21120122; PubMed Central PMCID: PMC2982730.
Randomized, controlled clinical trials
Cole RJ, Smith JS, Alcalá YC, Elliott JA, Kripke DF. Bright-light mask treatment of delayed sleep phase syndrome. J Biol Rhythms. 2002 Feb;17(1):89-101. PubMed PMID: 11837952.
Dahlitz M, Alvarez B, Vignau J, English J, Arendt J, Parkes JD. Delayed
Kayumov L, Brown G, Jindal R, Buttoo K, Shapiro CM. A randomized, double-blind, placebo-controlled crossover study of the effect of exogenous melatonin on delayed sleep phase syndrome. Psychosom Med. 2001 Jan-Feb;63(1):40-8. PubMed PMID: 11211063.
Mundey K, Benloucif S, Harsanyi K, Dubocovich ML, Zee PC. Phase-dependent treatment of delayed sleep phase syndrome with melatonin. Sleep. 2005 Oct;28(10):1271-8. PubMed PMID: 16295212. Thirteen subjects only.
Nagtegaal JE, Kerkhof GA, Smits MG, Swart AC, Van Der Meer YG. Delayed sleep phase syndrome: A placebo-controlled cross-over study on the effects of melatonin administered five hours before the individual dim light melatonin onset. J Sleep Res. 1998 Jun;7(2):135-43. PubMed PMID: 9682186. Thirty subjects.
Saxvig IW, Wilhelmsen-Langeland A, Pallesen S, Vedaa O, Nordhus IH, Bjorvatn B. A randomized controlled trial with bright light and melatonin for delayed sleep phase disorder: effects on subjective and objective sleep. Chronobiol Int. 2014 Feb;31(1):72-86. PubMed PMID: 24144243.
Sharkey KM, Carskadon MA, Figueiro MG, Zhu Y, Rea MS. Effects of an advanced sleep schedule and morning short wavelength light exposure on
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Wasdell MB, Jan JE, Bomben MM, Freeman RD, Rietveld WJ, Tai J, Hamilton D, Weiss MD. A randomized, placebo-controlled trial of controlled release melatonin treatment of delayed sleep phase syndrome and impaired sleep maintenance in children with neurodevelopmental disabilities. J Pineal Res. 2008 Jan;44(1):57-64. PubMed PMID: 18078449.
Wilhelmsen-Langeland A, Saxvig IW, Pallesen S, Nordhus IH, Vedaa Ø, Lundervold AJ, Bjorvatn B. A randomized controlled trial with bright light and melatonin for the treatment of delayed sleep phase disorder: effects on subjective and objective sleepiness and cognitive function. J Biol Rhythms. 2013 Oct;28(5):306-21. PubMed PMID: 24132057.
Burgess HJ, Revell VL, Molina TA, Eastman CI. Human phase response curves to three days of daily melatonin: 0.5 mg versus 3.0 mg. J Clin Endocrinol Metab. 2010 Jul;95(7):3325-31. PubMed PMID: 20410229; PubMed Central PMCID: PMC2928909.
Dagan Y, Yovel I, Hallis D, Eisenstein M, Raichik I. Evaluating the role of melatonin in the long-term treatment of delayed sleep phase syndrome (DSPS). Chronobiol Int. 1998 Mar;15(2):181-90. PubMed PMID: 9562922.
Lack LC, Wright HR. Treating chronobiological components of chronic insomnia. Sleep Med. 2007 Sep;8(6):637-44. Review. PubMed PMID: 17383935.
Lovato N, Micic G, Gradisar M, Ferguson SA, Burgess HJ, Kennaway DJ, Lack L. Can the circadian phase be estimated from self-reported sleep timing in patients with Delayed Sleep Wake Phase Disorder to guide timing of chronobiologic treatment? Chronobiol Int. 2016;33(10):1376-1390. PubMed PMID: 27611743.
Takeshima M, Shimizu T, Echizenya M, Ishikawa H, Kanbayashi T. Inpatient phase-advance therapy for delayed sleep-wake phase disorder: a retrospective study. Nat Sci Sleep. 2018 Oct 12;10:327-333. PubMed PMID: 30349414; PubMed Central PMCID: PMC6188015.
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