Obstructive sleep apnea (OSA) is a common nocturnal breathing disorder characterized by recurrent upper airway obstruction during sleep, leading to sleep fragmentation and intermittent hypoxemia. The apnea-hypopnea index (AHI) is the most widely used clinical metric to assess OSA severity; however, the AHI fails to capture the full physiological burden caused by recurrent oxygen desaturations. Consequently, quantifying hypoxemia, the cumulative burden of oxygen desaturations, has become crucial for assessing the physiological impact of OSA more comprehensively. Furthermore, studies have illustrated that hypoxemia is associated with cardiovascular morbidity, metabolic dysfunction, and neurocognitive impairment in OSA patients. This narrative review aims to explore various methods used to quantify nocturnal hypoxemia from sleep recordings and discuss the different approaches, and their association with OSA-related comorbidities. The discussed metrics include traditional measures and newer parameters that provide a more detailed quantification of oxygen desaturation, including separate characterization of desaturation and re-saturation dynamics as well as integrated measures of the overall hypoxic load. Additionally, this review discusses how these more detailed metrics have provided further insight into the associations between OSA-related hypoxemia and clinically relevant outcomes, including cardiometabolic comorbidities and impaired daytime functioning. This narrative review emphasizes the need for diagnostic modifications and advocates for the integration of metrics quantifying hypoxemia into routine clinical practice to enable early recognition of the health risks associated with OSA.
The goals of this review were to (1) identify and describe recent and forthcoming research on the treatment of insomnia in trauma-exposed individuals, and (2) highlight clinical implications and research gaps. We included trials with rigorous insomnia and trauma exposure inclusion criteria; uncontrolled trials were excluded. The final sample included 11 studies published between 2020 and 2025 that described outcomes from eight independent clinical trials. Additionally, we identified nine recently completed or ongoing clinical trials. Most trials included behavioral interventions. Behavioral interventions involved delivering standard insomnia treatment in trauma-exposed samples, adapting the content of insomnia treatment for patients with comorbid posttraumatic stress disorder (PTSD), or combining insomnia treatment with treatments for PTSD and/or nightmares. Trial samples were predominately male veterans/military personnel. Attrition problems occurred across multiple studies. More high-quality clinical trials are needed to elucidate optimal insomnia treatment pathways for trauma-exposed individuals.
In this review about the neurobiology of insomnia, we summarize the currently known areas of neurobiological differences in insomnia structured by polysomnography, stress system, electroencephalography, neuroimaging and genetics. In each chapter we note early seminal work, recent additions and current meta-analytical work, thereby synthesizing available knowledge. While heritability of insomnia is significant, many genes are involved. Similarly, in brain morphology no single region stands out. The most common findings across modalities of investigation relate to hyperarousal as well as emotional dysregulation. The considerable pathophysiological heterogeneity in insomnia may still be assessed by neurophysiological methods and used to inform therapeutic approaches. Despite promising methodological advances, group studies converge on relatively unspecific terms such as hyperarousal, and detailed pathophysiological mechanisms are underreported. The investigation of better differentiated subgroups and of intraindividual changes, e.g. therapy effects, should yield more insight in the future.
Obstructive sleep apnea (OSA) represents a widespread condition, yet dependable, rapid methods for broad screening remain scarce. Recent research has increasingly explored artificial intelligence (AI) applied to heart rate variability (HRV) analysis as an innovative strategy for identifying this disorder. The current study therefore sought to determine, via meta-analysis, the diagnostic performance of machine learning techniques in OSA detection using HRV parameters extracted from electrocardiography. PubMed, Scopus, and Web of Science were screened for studies up to November 2025. Diagnostic capability of HRV-based approaches for OSA identification was evaluated using overall diagnostic accuracy measures. Analyses were conducted with MetaDisc and Stata software. Sensitivity reached 0.88 (95
The cardiovascular health implications of insomnia, a highly prevalent sleep disorder, are increasingly acknowledged. A growing body of research suggests that insomnia may be associated with heightened risk of atrial fibrillation (AF), the most common cardiac arrhythmia. In this review, we synthesize contemporary evidence on the epidemiological, clinical, and pathophysiological data linking insomnia to AF. Findings from population-based and clinical investigations support an independent relationship between insomnia and risk of prevalent and incident AF and AF-related outcomes, especially among younger adults. Objective measures of poor sleep quality are also predictive of AF. Multiple pathophysiological mechanisms have been implicated, including autonomic dysfunction, hypothalamic-pituitary-adrenal axis activation, and systemic inflammation. While data on insomnia treatment in AF patients are lacking, studies suggest potential benefits of cognitive behavioral therapy even beyond sleep restoration. Insomnia is an underrecognized, modifiable risk factor for AF. Integrating screening and treatment for insomnia within cardiovascular care may enhance patient outcomes.
To summarize current concepts in the pathophysiology, diagnosis, and management of central sleep apnoea (CSA), with a focus on periodic breathing in heart failure patients, and to critically appraise the role, safety, and indications of adaptive servo‑ventilation (ASV) based on recent evidence and guideline updates. The evaluation of all available data from randomized and observational studies, including those with modern devices, meta‑analyses and large registries show no excess mortality with ASV in any heart failure subtype and demonstrate sustained improvements in sleep‑disordered breathing severity and patient‑reported outcomes. Based on these re-assessments, recent guidelines and scientific statements suggest potential benefits and lead to positive recommendations for clinical practice. Contemporary evidence confirms ASV as the most effective therapy to normalize CSA and periodic breathing, no longer justifying previous safety concerns. Future research should refine patient selection and define optimal integration with other therapies.
Sleep disturbances are a common, heterogeneous comorbidity of autism spectrum disorder (ASD). This systematic review updates the field on sleep in ASD over 2022–2026, with attention to how the evidence has evolved. Eighty-nine studies met inclusion criteria. Sleep disturbance remained more prevalent in autistic individuals than in typically developing peers (47–84
Community-engaged research (CEnR) and implementation science can address gaps in translating evidence-based interventions to real-world practice by considering the needs of patients/families, clinicians, and contexts. This review summarizes recent pediatric sleep intervention research that incorporates CEnR and/or implementation science principles. We also identify key areas for future research. Most reviewed studies incorporated CEnR methods during intervention development, adaptation, and/or pilot testing. Studies with community members collaborating in named research team roles were rare. Although some studies evaluated intervention acceptability, feasibility, and fidelity, very few used established implementation science theories, models, or frameworks, and even fewer focused on developing and testing implementation strategies. It is critical to establish sleep researcher-community partnerships that promote community empowerment and capacity-building, and to conduct implementation strategy research. We encourage researchers to further integrate CEnR and implementation science to advance pediatric sleep health and address the many gaps in care.
Insomnia disorder is a prevalent and impairing sleep-wake disorder characterized by persistent difficulty initiating or maintaining sleep, accompanied by daytime impairment. Cognitive behavioral therapy for insomnia (CBT-I) is the recommended first-line treatment and has a strong evidence base. Building on this foundation, recent work has increasingly focused on translating these advances into accessible and scalable interventions. This review (1) highlights key challenges in the delivery of insomnia interventions that constrain equitable access and (2) examines emerging approaches that may address these gaps. Recent research has identified four primary challenges limiting equitable access to insomnia interventions: high comorbidity with mental health and other sleep and circadian disorders, limited testing and adaptation outside of academic settings, a shortage of trained providers, and structural barriers related to funding and reimbursement. In response, growing evidence supports transdiagnostic treatment approaches, implementation strategies for real-world settings, delivery by non-specialist providers, brief and single-session interventions, and digital and stepped care models as promising pathways to improve access and scalability. Our review underscores the importance of moving beyond testing efficacy to address the practical and structural barriers that limit access to evidence-based insomnia interventions. Advancing research that prioritizes real-world application remains essential for narrowing the longstanding gap between evidence and practice and to improve equitable access to effective insomnia interventions.
The goal of this paper is to describe the process of advocacy for sleep clinicians and researchers. We draw upon our own experiences as sleep advocates and include resources from the literature. While virtually every area of health and well-being is affected by sleep and circadian biology, including cardiovascular and cerebrovascular disease, obesity and metabolism, and mental health, sleep clinicians and researchers are often reluctant to advocate for our field, including communicating the importance of sleep, to lawmakers and other public stakeholders. We discuss the barriers along with rewards of sleep advocacy and present a primer on how to get started as a sleep advocate. Sleep clinicians and researchers can play a critical role in advocating the importance of sleep and circadian biology for human health and well-being. We need to support our clinicians and resources in this endeavor.
Sleep disturbances are highly prevalent among youth with attention-deficit/hyperactivity disorder (ADHD) and contribute to emotional, cognitive, and functional impairments. Although historically under-addressed in ADHD treatment, there is increasing recognition of sleep as a critical intervention target. This paper synthesizes recent advances in behavioral sleep interventions for youth with ADHD, emphasizing developmental considerations spanning early childhood, middle childhood, and adolescence. Across developmental periods, growing evidence supports the feasibility and effectiveness of behavioral sleep interventions, particularly for improving parent- and self-reported sleep outcomes. We also examine the limited literature on integrating sleep-focused strategies into established evidence-based behavioral treatments for ADHD, highlighting opportunities and challenges for embedding sleep within existing care models. We identify key emerging directions, including the need for developmentally-tailored and mechanistically-informed interventions, increased focus on circadian and sleep regularity processes, and scalable delivery approaches leveraging digital and integrated care settings. Advancing this work holds promise for improving both nighttime sleep and daytime functioning for youth with ADHD and their families.
Comorbid insomnia and obstructive sleep apnea (COMISA) is increasingly viewed as more than two coexisting sleep disorders. This review asks whether COMISA reflects a distinct phenotype driven by mechanistic convergence, how heterogeneous it is across patients, and what that means for diagnosis and treatment. Recent studies show COMISA is common, linked to greater sleep fragmentation, and higher cardiometabolic and psychiatric burden than either disorder alone. Mechanistic work supports bidirectional interaction between ventilatory instability and chronic hyperarousal, with autonomic and EEG findings suggesting persistent sympathetic activation and cortical hyperactivation. Treatment studies indicate that PAP and CBT-I each help, but single-modality treatment often leaves residual symptoms; combined, phenotype-informed care appears more effective. The evidence supports COMISA as a clinically important, heterogeneous convergence phenotype rather than a simple comorbidity. Future research should prioritize longitudinal outcomes, biomarker-based phenotyping, and endotype-stratified trials. This shift could move COMISA care toward more precise, mechanism-guided management.
This review aims to synthesize the literature on behavioral treatments of sleep disturbances in the context of substance use and substance use disorders. Standard behavioral interventions like cognitive-behavioral therapy for insomnia (CBT-I) are generally effective for treating sleep disturbances in people who use a range of substances. While alcohol has the largest evidence base, research on cannabis, nicotine, and other substances is growing. In addition to CBT-I, other behavioral interventions (e.g., Transdiagnostic Intervention for Sleep and Circadian Dysfunction or TSC) may also be effective in targeting sleep and circadian risk factors for substance use, such as evening chronotype. The evidence is mixed as to whether treating sleep problems has any downstream effects on substance use outcomes (e.g., reducing use, related problems, and/or craving), with promising evidence emerging for cannabis outcomes in particular. Behavioral sleep interventions are effective for treating sleep problems among people who use substances, but greater sample diversity is needed to determine if demographic factors such as sex or race influence outcomes. Additionally, larger trials with longer follow-ups are needed to determine the extent to which improving sleep reduces substance-related outcomes, and if so, what may be the potential mechanisms.
This narrative review summarizes the evidence for behavioral interventions addressing sleep disturbance (i.e., insomnia) in cancer populations. Implementation considerations and future research directions are provided. Support is strong for Cognitive Behavioral Therapy for Insomnia (CBTI) in cancer populations. Mindfulness and acceptance-based therapies show promise for improving sleep disturbance, especially when integrated with sleep restriction and stimulus control; however, comparative efficacy to CBTI should be further investigated. Psychologists most commonly deliver behavioral insomnia interventions. Recent work shows other clinicians (e.g., nurses) can also deliver these treatments, and this shift may improve the shortage of behavioral sleep providers in the oncology setting. CBTI is the “gold standard” for treating insomnia in cancer patients. Future research should expand its focus beyond breast cancer samples and examine stepped care models that leverage digital technologies (e.g., mobile applications, wearables) to address access and resources barriers limiting clinical implementation.
Sleep health in childhood is critical for growth and development, however, neurodivergent children (e.g., children with attention deficit hyperactivity disorder, autism, Down syndrome) experience significantly more sleep challenges compared to their peers. Recent intervention research has begun to address specific challenges that contribute to poor sleep health for neurodivergent children. This review identifies behavioral sleep interventions published in the past 5 years that are developed for neurodivergent children and examines the impact of these interventions on sleep health. Evidence highlights an increase in behavioral sleep intervention research targeting the sleep health of neurodivergent children. In addition to the traditional behavioral sleep intervention components, these interventions target neurodivergent-specific experiences that impact sleep difficulties like sensory processing differences, medication effects, and familial supports. Recent evidence affirms that behavioral interventions improve sleep health and positively impact daytime functioning for neurodivergent children. Behavioral interventions developed or adapted for neurodivergent children to target specific challenges they experience have emerging efficacy. Future research should aim to increase the generalizability of the preliminary findings with larger, more diverse samples and engagement with key community members to improve implementation success.
This review examines the role of core body temperature as an active physiological modulator of synaptic plasticity across the circadian cycle and sleep–wake states, with a specific focus on their relevance for mental health. The aim is to integrate evidence from cellular and clinical neuroscience to clarify whether thermoregulatory dysregulation may contribute to plasticity alterations observed in psychiatric disorders. Recent experimental work shows that even modest brain temperature fluctuations modulate neuronal excitability, neurotransmission, and the balance between long-term potentiation and long-term depression. Circadian and sleep-dependent temperature oscillations are tightly coupled to metabolic activity, neurovascular dynamics, and network states, supporting synaptic potentiation during wakefulness and renormalization during NREM sleep. Clinical studies increasingly report blunted or elevated core temperature rhythms in mood and psychotic disorders, although direct links to plasticity markers in humans remain elusive. Collectively, current evidence supports that temperature may represent a biologically meaningful variable capable of modulating synaptic plasticity across time. Thermoregulatory dysregulation may therefore represent a transdiagnostic mechanism contributing to vulnerability and persistence of mental disorders, warranting targeted experimental investigation.
Chronotype is increasingly recognized as relevant to a range of psychiatric conditions, but its clinical significance and mechanistic role remain poorly understood. This review summarizes recent evidence on chronotype and psychiatric disorders published since 2018, and highlights key developments in study design, measurement, and proposed pathways linking chronotype to mental health. Eveningness continues to show the strongest and most consistent associations with depressive disorders, including major depressive disorder and seasonal affective disorder. Supporting evidence linking eveningness to bipolar disorder, suicidality, and addictive behaviors has expanded, based on several longitudinal cohort studies. Findings for anxiety disorders, post-traumatic stress disorder, obsessive-compulsive disorder, attention-deficit/hyperactivity disorder, autism spectrum disorder, personality disorders, and psychotic disorders remain more mixed, partly reflecting heterogeneity in samples and chronotype definitions. A small but increasing number of studies incorporate objective markers (e.g., actigraphy, dim-light melatonin onset) and intensive designs (e.g., ecological momentary assessment), allowing for more precise estimates of sleep–wake timing. However, these multimethod approaches remain limited, and findings across modalities are inconsistent. Chronotype is robustly associated with multiple psychiatric outcomes, most notably depression, substance use, and aspects of bipolar disorder and suicidality. Despite more longitudinal and multimethod evidence, the literature remains dominated by cross-sectional designs and subjective measures that may conflate biological phase with behavioral or contextual factors. Future work should integrate behavioral, biological, and environmental data across time to determine whether chronotype reflects a causal influence, a vulnerability marker, or an epiphenomenon of psychopathology.
There is accumulating evidence that sleep-wake and circadian targeted interventions (chronotherapeutics) are effective in the management of bipolar disorders (BD). However, little is known about chronotherapeutics in the early course of BD. This targeted narrative review aims to provide an update of what we have learned from trials in this area in the past three years. Some progress has been made in the investigation of the effects of a small number of chronotherapeutics (e.g., lithium, Interpersonal and Social Rhythm Therapy) on mood, sleep, sleep-wake cycles, or circadian rest-activity rhythms in the early course of BD. One particularly noteworthy finding from a randomised controlled trial is that lithium influences the timing of rest-activity rhythms in individuals early in the course of BD, and that changes in rest-activity rhythms might precede changes in mood states. We did not identify new studies on bright light therapy, dark therapy, or melatonergic or orexinergic agents that were relevant to the early course of BD (as most studies were in middle-aged or older adults with long-standing course of illness). Despite the promise of chronotherapeutics in the management toolkit for BD, there is a dearth of recent clinical trial evidence focused on recent-onset, youth, and early course samples. We encourage researchers working on chronotherapeutics in BD to focus efforts on the early course of BD (or at minimum conduct sub-analyses in recent-onset cases) and to examine objective measures of sleep-wake and circadian rhythms (e.g., actigraphy) as mediators or moderators of clinical effects (both symptom and functional improvements).
To summarize existing evidence of associations between religion and spirituality in relation to multiple dimensions of sleep health, illuminate strengths and limitations of the existing literature, and outline gaps that inform opportunities for future research. Positive dimensions of religion and spirituality, such as spiritual well-being, supportive coping, and community integration, were generally associated with better sleep outcomes across global populations. Adverse experiences, including doubt, conflict, and spiritual struggle, were often associated with poorer sleep. Among the 59 included studies, most were cross-sectional and relied on self-reported measures, used inconsistent conceptualizations of religion and spirituality, did not sufficiently assess potentially adverse religious or spiritual experiences, and were limited to certain geographic regions of the world (e.g., North America and Southwest Asia). Positive dimensions of religion and spirituality (e.g., meaning, coping) were generally associated with better sleep, while struggles and doubt were associated with poorer sleep. Future research that employs longitudinal and experimental designs, validated multidimensional measures, objective sleep assessments, and diverse populations is needed to clarify mechanisms and inform culturally responsive approaches to promoting sleep health.
REM sleep behavior disorder (RBD) is a well-established prodromal marker of α-synucleinopathies, including Parkinson’s disease, dementia with Lewy bodies, and multiple system atrophy. Over 80
