What strategies can decrease the risk of relapse in Delayed Sleep Phase Syndrome (DSPS) and improve long-term success without chronotherapy, despite unavoidable disruptions to strict schedules?

From the Guidelines

To decrease the risk of relapse in Delayed Sleep Phase Syndrome (DSPS) without relying on chronotherapy or strict schedules, focus on consistent behavioral interventions, such as Cognitive Behavioral Therapy for Insomnia (CBT-I) and stimulus control, as these approaches have been shown to be effective in improving sleep quality and reducing the risk of relapse. According to the American Academy of Sleep Medicine systematic review and meta-analysis 1, CBT-I, which combines cognitive therapy strategies with education about sleep regulation, stimulus control instructions, and sleep restriction therapy, is a highly effective treatment for chronic insomnia disorder in adults.

Key components of CBT-I include:

• Stimulus control instructions to associate the bed and bedroom with sleep
• Sleep restriction therapy to limit time in bed and increase sleep drive
• Sleep hygiene education to promote healthy sleep habits
• Relaxation training and counterarousal methods to reduce stress and anxiety

In addition to CBT-I, other behavioral interventions such as brief therapies for insomnia (BTIs) and mindfulness approaches can also be effective in reducing the risk of relapse in DSPS. BTIs, which typically consist of education about sleep regulation and behaviors that promote or interfere with sleep, along with a tailored behavioral prescription, can be a useful alternative to CBT-I for patients who prefer a more abbreviated treatment approach 1. Mindfulness approaches, which emphasize a nonjudgmental state of heightened awareness of one's thoughts, emotions, or experiences, can also be beneficial in reducing stress and anxiety and improving sleep quality 1.

While light therapy and melatonin supplementation may also be useful in managing DSPS, the evidence for these interventions is less strong, and their use should be individualized based on patient preferences and needs. The American Academy of Sleep Medicine clinical practice guideline for the treatment of intrinsic circadian rhythm sleep-wake disorders suggests that strategically timed melatonin may be effective in treating Delayed Sleep-Wake Phase Disorder (DSWPD) in adults, but the quality of evidence is low 1.

Overall, a comprehensive treatment approach that incorporates behavioral interventions, such as CBT-I and stimulus control, along with lifestyle adjustments and environmental modifications, is likely to be the most effective in reducing the risk of relapse in DSPS and improving long-term success.

From the Research

Strategies to Decrease Relapse Risk in DSPS

To decrease the risk of relapse in Delayed Sleep Phase Syndrome (DSPS) and improve long-term success without chronotherapy, despite unavoidable disruptions to strict schedules, several strategies can be employed:

• Melatonin treatment: Melatonin administration 1 hour prior to the desired bedtime, combined with behavioral sleep-wake scheduling, has been shown to improve sleep initiation and reduce sleep-related impairments in DSPS patients 2.
• Gradual advancement of rise time: Gradually advancing rise times, alongside timed bright light and melatonin administration, can produce a phase advance and improve sleep timing 3.
• Appropriate light exposure: Exposure to bright light during the day can help regulate the circadian rhythm and improve sleep timing 3, 4.
• Evening routine: Developing an evening routine that minimizes arousal-increasing activities can help improve sleep quality and reduce the risk of relapse 4.
• Behavioral sleep-wake scheduling: Implementing a consistent sleep-wake schedule and establishing a relaxing bedtime routine can help regulate the circadian rhythm and improve sleep timing 2, 4.

Factors Contributing to Relapse

Several factors can contribute to relapse in DSPS patients, including:

• Circadian rhythm period length: A longer than normal circadian rhythm period length (tau) can make it difficult for DSPS patients to phase advance and maintain a conventional sleep schedule 5.
• Disruptions to strict schedules: Unavoidable disruptions to strict schedules can lead to relapse in DSPS patients, highlighting the need for flexible and adaptable treatment strategies.
• Lack of long-term treatment: Termination of treatment can cause relapse into delayed sleep times, emphasizing the importance of long-term treatment and maintenance strategies 3.