Comorbid insomnia and sleep disordered breathing.

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.