Does comorbid obstructive sleep apnea impair the effectiveness of cognitive and behavioral therapy for insomnia?

Abstract

CBT-i is an effective treatment in the presence of comorbid OSA. This information offers support for the suggestion that patients with comorbid insomnia and OSA should be treated with CBT-i prior to the treatment of the OSA.

Co-Morbid Insomnia and Sleep Apnea (COMISA): Prevalence, Consequences, Methodological Considerations, and Recent Randomized Controlled Trials

“…In 2017, we reviewed a large number of studies which indicated an additive and substantial impairment to sleep, daytime functioning, depressive and psychiatric symptoms, and quality of life among COMISA patients [40]. Since 2017, a number of other studies have confirmed associations between COMISA and increased depressive and anxiety symptoms, daytime sleepiness, reduced quality of life, neurocognitive performance, and sleep quality compared to patients with either insomnia or OSA alone [46][47][48][49][50][51][52]. Hence, a large body of evidence has left little doubt that COMISA is a common disorder, which is associated with substantial impairments to nocturnal sleep, daytime functioning, and quality of life.…”

“…To investigate the measurement of insomnia symptoms in the presence of OSA, Wallace and Wohlgemuth [62] recently examined profiles and predictors of insomnia severity index (ISI) questionnaire responses among 630 veterans with OSA. The ISI [54] is a brief, and valuable questionnaire measure of insomnia presence and severity, which has been utilized in several hundred insomnia treatment studies, including COMISA research [52,[63][64][65]. The ISI includes seven self-report items, including three nocturnal items (difficulties falling asleep, staying sleep, and waking up too early), and four daytime items (satisfaction with sleep, daytime functioning interference, quality of life impairment, and worry/distress).…”

“…Wallace and Wohlgemuth propose that when administered to OSA patients, the ISI should be scored according to a 'nocturnal' sub-score (comprising the first three items, ranging from 0 to 12), and a 'daytime' sub-score (comprising the subsequent four items, ranging from 0 to 16). This 'nocturnal' score has also recently been investigated in other insomnia research [66,67], and has previously been utilized in several COMISA treatment studies [52,63,64].…”

“…This finding has led several groups to suggest that COMISA patients should be referred for insomnia treatment before commencing CPAP therapy. CBTi is the recommended 'first line' treatment for insomnia, and appears to be effective in the presence of co-morbid OSA [8,9,52]. Although several early pilot studies and a randomized controlled trial (RCT) reported mixed findings [69,[75][76][77], more recent quasi-experimental and RCT data support the effectiveness of CBTi in COMISA patients [52,64,78,79].…”

“…CBTi is the recommended 'first line' treatment for insomnia, and appears to be effective in the presence of co-morbid OSA [8,9,52]. Although several early pilot studies and a randomized controlled trial (RCT) reported mixed findings [69,[75][76][77], more recent quasi-experimental and RCT data support the effectiveness of CBTi in COMISA patients [52,64,78,79]. For example, we previously reported a chart review of 455 insomnia patients treated with CBTi at an out-patient hospital insomnia treatment service, and found that there were no significant differences in insomnia improvements during treatment between the 141 patients with co-morbid OSA, and the 314 patients with insomnia alone [52].…”