Bi-directional relationships between co-morbid insomnia and sleep apnea (COMISA)

Alexander Sweetman, Leon Lack, R. Doug McEvoy, Simon Smith, Danny J. Eckert, Amal Osman, Jayne C. Carberry, Douglas Wallace, Phuc D. Nguyen, Peter Catcheside

Research output: Contribution to journalReview articlepeer-review


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.

Original languageEnglish (US)
Article number101519
JournalSleep Medicine Reviews
StatePublished - Dec 2021


  • Cognitive behavioral therapy for insomnia (CBTi)
  • Continuous positive airway pressure (CPAP)
  • Mechanisms
  • Precision medicine
  • Sleep disordered breathing
  • Upper airway

ASJC Scopus subject areas

  • Pulmonary and Respiratory Medicine
  • Neurology
  • Clinical Neurology
  • Physiology (medical)


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