Sleep medicine reviewsJul 6, 2021

Two-way links between insomnia and sleep apnea happening together

Circadian Biology Weekly Brief ↗PubMed ↗DOI ↗

Updated Apr 3, 2026

Abstract

Approximately 30-50% of patients with obstructive sleep apnea report clinically significant insomnia symptoms.

Co-morbid insomnia and sleep apnea (COMISA) is associated with greater morbidity compared to having either condition alone.
Patients with chronic insomnia have a 30-40% likelihood of fulfilling diagnostic criteria for obstructive sleep apnea.
Complex diagnostic decisions are required for clinicians managing patients with COMISA.
Potential bi-directional relationships between insomnia and obstructive sleep apnea may influence both conditions' development and management.
A conceptual model of COMISA is proposed to enhance understanding of these relationships and inform future research.

Simplified

Insomnia and obstructive sleep apnea (OSA) commonly co-occur. Approximately 30-50% of patients with OSA report clinically significant insomnia symptoms, and 30-40% of patients with chronic insomnia fulfil diagnostic criteria for OSA. Compared to either insomnia or OSA alone, co-morbid insomnia and sleep apnea (COMISA) is associated with greater morbidity for patients, complex diagnostic decisions for clinicians, and reduced response to otherwise effective treatment approaches. Potential bi-directional causal relationships between the mechanisms and manifestations of insomnia and OSA could play an integral role in the development and management of COMISA. A greater understanding of these relationships is required to guide personalized diagnostic and treatment approaches for COMISA. This review summarizes the available evidence of bi-directional relationships between COMISA, including epidemiological research, case studies, single-arm treatment studies, randomized controlled treatment trials, and objective sleep study data. This evidence is integrated into a conceptual model of COMISA to help refine the understanding of potential bi-directional causal relationships between the two disorders. This theoretical framework is essential to help guide future research, improve diagnostic tools, determine novel therapeutic targets, and guide tailored sequenced and multi-faceted treatment approaches for this common, complex, and debilitating condition.

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Funding

Competing interests

Conflicts of interest Financial conflicts of interest AS, LL and DMc report receiving research funding support from competitive grants from ResMed Australia; Philips Respironics USA. LL reports receiving research funding support and has shares in Re-time Pty Ltd (Adelaide, Australia). Outside the current study, DJE has a Cooperative Research Centre (CRC)-P grant (Industry partner Oventus Medical) and receives research income from Bayer and Apnimed and serves as a consultant. PC reports receiving grants from NHMRC and Defence Science and Technology outside this study. The remaining authors report no relevant financial conflicts of interest. Non-financial conflicts of interest Outside the current study DJE and PC report receiving equipment loan support from Philips. AS, LL, and DMc report receiving equipment support from Philips and ResMed. The remaining authors report no relevant non-financial conflicts of interest.

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Two-way links between insomnia and sleep apnea happening together

Abstract

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Funding

Competing interests

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