A randomized controlled trial of cognitive behavioral therapy for insomnia and PAP for obstructive sleep apnea and comorbid insomnia: effects on nocturnal sleep and daytime performance.
Level 2 - randomized trial
Individual randomized controlled trial
PubMed 34648425 · doi:10.5664/jcsm.9696
What was done
A partial factorial randomized controlled trial evaluated treatment sequencing of cognitive behavioral therapy for insomnia (CBT-I) and positive airway pressure (PAP) in 118 individuals with comorbid insomnia and obstructive sleep apnea. Participants were randomized to receive CBT-I followed by PAP, self-monitoring followed by CBT-I concurrent with PAP, or self-monitoring followed by PAP only. Assessments occurred at baseline, PAP titration, and at 30 and 90 days after PAP initiation. Measured outcomes included sleep diary, wrist actigraphy, the Flinders Fatigue Scale, Epworth Sleepiness Scale, Functional Outcome of Sleep Questionnaire, and cognitive-emotional measures.
What was found
A significant main effect of time occurred across all three arms (all P < .05) for diary-measured sleep (decreased sleep onset latency and wake after sleep onset; increased total sleep time and sleep efficiency), actigraphy-measured sleep (decreased wake after sleep onset; increased sleep efficiency), and daytime functioning (reduced Epworth Sleepiness Scale and Flinders Fatigue Scale; increased Functional Outcome of Sleep Questionnaire). CBT-I was superior to PAP alone and self-monitoring in reducing diary-measured sleep onset latency and wake after sleep onset, increasing sleep efficiency, and improving Functional Outcome of Sleep Questionnaire and Flinders Fatigue Scale scores. The abstract did not report numerical effect sizes, point estimates, or confidence intervals.
Why it matters
Comorbid insomnia and sleep apnea is challenging to treat because insomnia can impair PAP tolerance and recovery. These findings demonstrate that integrating CBT-I either before or concurrently with PAP therapy achieves faster resolution of sleep disturbance and daytime impairment than PAP alone.
Limits
The abstract does not report numerical means, effect sizes, standard deviations, or confidence intervals. Follow-up was limited to 90 days post-PAP initiation, the sample size across three arms was modest (n = 118), and objective PAP adherence rates were not reported in the abstract.
Cited by
- supports CBT-I is effective for improving insomnia in patients with sleep apnea before their sleep apnea is treated.