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Insomnia and excessive daytime sleepiness represent two important public-health problems that require accurate diagnosis and effective treatment. Obstructive sleep apnea (OSA) is highly prevalent [1] and may be related to both excessive daytime sleepiness (EDS) and insomnia. Several studies have shown that OSA is associated with EDS that represents a frequent and serious symptom of the syndrome [2, 3]. On the other hand, other studies [4, 5] report that many OSA patients, including some patients with severe OSA, do not experience excessive sleepiness. The sleepy and non-sleepy phenotypes are now commonly used terms in OSA [6]. When suspicion of OSA exists, physicians should not defer a sleep study for patients simply because they deny excessive daytime sleepiness by clinical history or score low on the Epworth sleepiness scale (ESS). Insomnia is another sleep disorder commonly associated with obstructed breathing during sleep, but this association has received less focus compared to excessive daytime sleepiness [7, 8]. Inconsistencies in the definitions and assessments of insomnia across studies hinder our understanding of the prevalence of co-morbid insomnia in OSA and limit the ability to compare findings across studies. Taking all the above into account, a recent review [7] reported insomnia to be present in 39–58 % of patients with OSA. In addition, the criteria for the insomnia diagnosis were recently changed, both in the Diagnostic and Statistical Manual for Mental disorders (DSM-V) [9] and in the International Classification of Sleep Disorders-3 (ICSD-3) [10]. The main change is that non-restorative sleep is no longer part of the insomnia diagnosis in DSM-V/ICSD-3. Nonrestorative sleep is reported to be more common in OSA patients than problems with sleep initiation and maintenance [7, 8]. Hence, the new insomnia criteria will probably reduce the reported prevalence of insomnia in OSA patients. In 1973, Guilleminault et al. [11] described the association between insomnia and obstructive sleep apnea, and called it “sleep-insomnia apnea syndrome.” The relationship between these two common sleep disorders is complex and in many points unclear. Based on published studies, there is a higher incidence of breathing disorders in insomniac patients than there is in the general population [7, 8, 12]. Lichstein et al. [13] demonstrated that high proportions of individuals, particularly the elderly, present this combined condition of undiagnosed sleep apnea and insomnia. Insomnia is primarily diagnosed clinically with a detailed medical, psychiatric, and sleep history. Polysomnography (PSG) is indicated when a sleeprelated breathing disorder or periodic limbmovement disorder is suspected, initial diagnosis is uncertain, treatment fails, or precipitous arousals occur with violent or injurious behavior. However, PSG is not indicated for the routine evaluation of transient insomnia, chronic insomnia, or insomnia associated with psychiatric disorders [14]. In this issue of Sleep and Breathing [15], Bjørn Bjorvatn et al. report their results related to the prevalence of insomnia and excessive sleepiness in relation to the presence and severity of OSA. The large included sample consisted of 1115 patients referred to a university hospital in Norway on suspicion of OSA. Obstructive sleep apnea was diagnosed and categorized based on a standard respiratory polygraphic sleep study using a type 3 portable monitor. The majority of included * Charalampos Mermigkis mermigh@gmail.com

Insomnia and excessive daytime sleepiness in obstructive sleep apnea: only different clinical phenotypes?