Comorbid Insomnia and Sleep Disordered Breathing
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SLEEP DISORDERS (S CHOKROVERTY, SECTION EDITOR)
Comorbid Insomnia and Sleep Disordered Breathing Robert N. Glidewell, PsyD, CBSM Address Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Sleep and Behavioral Health Sciences Section, National Jewish Health, Denver, CO, USA Behavioral Sleep Medicine, LLC, Colorado Springs, CO 80907, USA Email: [email protected]
Published online: 25 October 2013 * Springer Science+Business Media New York 2013
Keywords Comorbid insomnia I Sleep disordered breathing I Obstructive sleep apnea I Multidisciplinary model I Cognitive-behavioral treatment of insomnia I Positive airway pressure I Upper airway surgery I Nasal dilator strip
Opinion statement Sufficient evidence has accumulated to warrant conceptualization of comorbid insomnia and sleep disordered breathing (SDB) as a distinct clinical syndrome. As such, diagnostic and treatment approaches should be founded on an integrated and multidisciplinary approach with equivalent clinical attention and priority given to both insomnia and respiratory aspects of patients’ presenting complaints. Several well established and effective treatments exist for both insomnia and SDB. Although questions of optimal treatment combination and sequence remain to be examined, current evidence provides preliminary guidance regarding the sequential or concurrent management of insomnia and sleep disordered breathing when comorbid. Unsatisfactory response to pharmacotherapy or cognitive-behavioral therapy for chronic insomnia should trigger evaluation for comorbid sleep-related breathing disturbance prior to more aggressive or off label pharmacotherapy. Presence and course of insomnia symptoms should be monitored closely in SDB patients with persistence of insomnia symptoms following SDB treatment prompting targeted treatment of insomnia. Aggressive treatment of insomnia prior to or in combination with SDB treatment may be particularly indicated in situations where insomnia is suspected to interfere with diagnosis or treatment of SDB. Insomnia and sleep disordered breathing appear to uniquely contribute to the morbidity of patients with this comorbidity. With this in mind, active engagement and monitoring of SDB and insomnia will often be necessary to achieve optimal outcomes.
Introduction Insomnia and sleep apnea are recognized as the two most prevalent sleep disorders [1••, 2••, 3–5]. Insomnia with Sleep Apnea: A New Syndrome is the title of a
small case series describing sleep maintenance insomnia due to sleep disordered breathing (SDB) published in Science in 1973 [6]. While this was
Comorbid Insomnia and Sleep Disordered Breathing the first publication to suggest the concurrence of insomnia and sleep-related breathing disturbance as a distinct clinical entity, investigations over the last 30 years have continued to support and attempt to characterize this syndrome [6–18; Glidewell, Roby, Orr, Unpublished Manuscript]. Based on this literature, Table 1 lists putative characteristics that may indicate presence of
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