Insomnia and obstructive sleep apnea (OSA) commonly co-occur which makes OSA difficult to treat with continuous positive airway pressure (CPAP). They conducted a randomized controlled trial in participants with OSA; and co-occurring insomnia to test the hypothesis that initial treatment with cognitive and behavioral therapy for insomnia (CBT-i); versus treatment as usual (TAU) would improve insomnia symptoms and increase subsequent acceptance and use of CPAP.

Cognitive behavioral therapy (CBT) improves use of continuous positive airway pressure (CPAP); in patients with comorbid insomnia; and obstructive sleep apnea (OSA), according to a new randomized controlled trial. Patients who received CBT for insomnia (CBT-i) used CPAP for an hour longer per night than those who received treatment as usual (TAU) and had improvements in insomnia symptoms; Dr. Alexander Sweetman of Flinders University in Bedford Park, Australia, and colleagues found.

Immediate CPAP treatment

“As CBT-i achieves substantial improvements in subjective insomnia symptoms; in patients with co-occurring OSA while at the same time improving adherence to CPAP; it should be considered best practice treatment for all such patients; apart from those with severe daytime sleepiness in whom immediate CPAP treatment may be required to mitigate accident risks,” the authors write in Sleep. Insomnia is common in OSA patients; and makes accepting and using CPAP more challenging, Dr. Sweetman and his colleagues note.

To investigate whether treating insomnia before starting CPAP would improve outcomes, they randomly assigned patients with moderate to severe OSA to four weeks of individual; or group CBT-i during the first six weeks of the study, or a waiting period of six weeks, before starting CPAP. Eight of the control group patients immediately rejected CPAP, versus one patient in the CBT-i group (11% vs. 1.4%, P=0.034).

Remission of insomnia

Patients in the CBT-i group used CPAP for 265.2 minutes per night; on average, compared to 204.5 minutes for the control group (P=0.023). The time increase was almost entirely due to the smaller number of patients immediately rejecting CPAP in the CBT-i group. The CBT-i group had more improvement in sleep-onset latency, wake after sleep onset and sleep efficiency between baseline and week 6 than the TAU group.

At six months, 53.2% of the CBT-i group achieved remission of insomnia, compared to 31.7% of the control group (P=0.02). However, patients in both groups had similar improvements in polysomnography or diary-measured sleep efficiency and other measures of sleep quality at six months. Daytime sleepiness, fatigue, depression, anxiety and stress were also similar for both groups at six months. “Sleep apnea patients should be assessed for co-morbid insomnia, which if present should be treated with cognitive and behavioral therapy to improve insomnia severity and increase CPAP use,” the authors conclude.