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Cognitive and behavioral therapy for insomnia increases the use of continuous positive airway pressure therapy in obstructive sleep apnea participants with comorbid insomnia: a randomized clinical trial

Published on Dec 24, 2019in Sleep4.571
· DOI :10.1093/SLEEP/ZSZ178
Alexander Sweetman5
Estimated H-index: 5
(Flinders University),
Leon Lack38
Estimated H-index: 38
(Flinders University)
+ 10 AuthorsR. Doug McEvoy30
Estimated H-index: 30
(Flinders University)
Abstract
STUDY OBJECTIVES: Insomnia and obstructive sleep apnea (OSA) commonly co-occur which makes OSA difficult to treat with continuous positive airway pressure (CPAP). We 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. METHODS: One hundred and forty-five participants with OSA (apnea-hypopnea index ≥ 15) and comorbid insomnia were randomized to either four sessions of CBT-i, or TAU, before commencing CPAP therapy until 6 months post-randomization. Primary between-group outcomes included objective average CPAP adherence and changes in objective sleep efficiency by 6 months. Secondary between-group outcomes included rates of immediate CPAP acceptance/rejection, and changes in; sleep parameters, insomnia severity, and daytime impairments by 6 months. RESULTS: Compared to TAU, participants in the CBT-i group had 61 min greater average nightly adherence to CPAP (95% confidence interval [CI] = 9 to 113; p = 0.023, d = 0.38) and higher initial CPAP treatment acceptance (99% vs. 89%; p = 0.034). The CBT-i group showed greater improvement of global insomnia severity, and dysfunctional sleep-related cognitions by 6 months (both: p < 0.001), and greater improvement in sleep impairment measures immediately following CBT-i. There were no between-group differences in sleep outcomes, or daytime impairments by 6 months. CONCLUSIONS: In OSA participants with comorbid insomnia, CBT-i prior to initiating CPAP treatment improves CPAP use and insomnia symptoms compared to commencing CPAP without CBT-i. OSA patients should be evaluated for co-occurring insomnia and considered for CBT-i before commencing CPAP therapy. CLINICAL TRIAL: Treating comorbid insomnia with obstructive sleep apnea (COMSIA) study: A new treatment strategy for patients with combined insomnia and sleep apnea, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=365184 Australian New Zealand Clinical Trials Registry: ACTRN12613001178730. Universal Trial Number: U1111-1149-4230.
  • References (51)
  • Citations (7)
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References51
Newest
#1Bjørn Bjorvatn (University of Bergen)H-Index: 52
#2Thomas Berge (Haukeland University Hospital)H-Index: 1
Last. Ingvild West Saxvig (Haukeland University Hospital)H-Index: 9
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Objective: To compare the effects of a self-help book for insomnia to that of sleep hygiene advice in a randomized controlled trial with follow-up after about three months among patients who were diagnosed with obstructive sleep apnea (OSA) and comorbid chronic insomnia, and who were concurrently initiating treatment with continuous positive airway pressure (CPAP). Method: In all, 164 patients were included. OSA was diagnosed and categorized based on a standard respiratory polygraphic sleep stud...
3 CitationsSource
#1Cathy A. Alessi (UCLA: University of California, Los Angeles)H-Index: 42
#2Jennifer L. Martin (UCLA: University of California, Los Angeles)H-Index: 43
Last. Karen R. JosephsonH-Index: 30
view all 12 authors...
4 CitationsSource
#1Grace W. Pien (JHUSOM: Johns Hopkins University School of Medicine)H-Index: 21
#2Lichuan Ye (NU: Northeastern University)H-Index: 10
Last. Allan I. Pack (UPenn: University of Pennsylvania)H-Index: 78
view all 9 authors...
Study Objectives: Distinct clinical phenotypes of obstructive sleep apnea (OSA) have been identified: Disturbed Sleep, Minimally Symptomatic, and Sleepy. Determining whether these phenotypes respond differently to standard treatment helps us to create a foundation for personalized therapies. We compared responses to positive airway pressure (PAP) therapy in these clinical OSA phenotypes. Methods: The study sample included 706 patients from the Icelandic Sleep Apnea Cohort with moderate-to-severe...
33 CitationsSource
#1Douglas M. Wallace (UM: University of Miami)H-Index: 14
#2Amy M. Sawyer (PSU: Pennsylvania State University)H-Index: 10
Last. Shirin Shafazand (UM: University of Miami)H-Index: 12
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Purpose There is limited information on the association between pre-treatment insomnia symptoms and dysfunctional sleep beliefs with continuous positive airway pressure (CPAP) adherence in veterans with obstructive sleep apnea (OSA). Our aims were to describe demographic and sleep characteristics of veterans with and without comorbid insomnia and determine whether pre-treatment insomnia symptoms and dysfunctional sleep beliefs predict CPAP use after 6 months of therapy.
11 CitationsSource
#1Alexander Sweetman (Flinders University)H-Index: 5
#2Leon Lack (Flinders University)H-Index: 38
Last. Jodie HarrisH-Index: 8
view all 5 authors...
Abstract Aims Comorbid insomnia and obstructive sleep apnea (OSA) represents a highly prevalent and debilitating condition; however, physicians and researchers are still uncertain about the most effective treatment approach. Several research groups have suggested that these patients should initially receive treatment for their insomnia before the sleep apnea is targeted. The current study aims to determine whether Cognitive and Behavioral Therapy for Insomnia (CBT-i) can effectively treat insomn...
16 CitationsSource
#1Alexander Sweetman (Flinders University)H-Index: 5
#2Leon Lack (Flinders University)H-Index: 38
Last. R. Doug McEvoy (Flinders University)H-Index: 30
view all 8 authors...
Insomnia and sleep apnoea are the two most common sleep disorders, found in 6% and 23–50% of the general population respectively. These disorders also frequently co-occur, with 39–58% of sleep apnoea patients reporting symptoms indicative of co-morbid insomnia. When these disorders co-occur, clinicians are faced with difficult treatment decisions, patients experience the additive detrimental impacts of both disorders, and the effectiveness of discrete treatments for each disorder may be impaired...
30 CitationsSource
#1Alexander Sweetman (Flinders University)H-Index: 5
#2Leon Lack (Flinders University)H-Index: 38
Last. D McEvoy (Flinders University)H-Index: 2
view all 11 authors...
1 CitationsSource
#2Thorarinn Gislason (University of Iceland)H-Index: 58
Last. Erla BjornsdottirH-Index: 10
view all 7 authors...
: The objective of this study was to evaluate the determinants of long-term adherence to positive airway pressure treatment among patients with obstructive sleep apnea, with special emphasis on patients who stop positive airway pressure treatment within 1 year. This is a prospective long-term follow-up of subjects in the Icelandic Sleep Apnea Cohort who were diagnosed with obstructive sleep apnea between 2005 and 2009, and started on positive airway pressure treatment. In October 2014, positive ...
15 CitationsSource
#1Tarja Saaresranta (UTU: University of Turku)H-Index: 22
#2Jan Hedner (University of Gothenburg)H-Index: 56
Last. Ludger Grote (University of Gothenburg)H-Index: 26
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Background Clinical presentation phenotypes of obstructive sleep apnoea (OSA) and their association with comorbidity as well as impact on adherence to continuous positive airway pressure (CPAP) treatment have not been established.
52 CitationsSource
#1Ronald McEvoyH-Index: 25
#2Nick A. AnticH-Index: 23
Last. Craig S. AndersonH-Index: 83
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BackgroundObstructive sleep apnea is associated with an increased risk of cardiovascular events; whether treatment with continuous positive airway pressure (CPAP) prevents major cardiovascular events is uncertain. MethodsAfter a 1-week run-in period during which the participants used sham CPAP, we randomly assigned 2717 eligible adults between 45 and 75 years of age who had moderate-to-severe obstructive sleep apnea and coronary or cerebrovascular disease to receive CPAP treatment plus usual car...
582 CitationsSource
Cited By7
Newest
Source
#1Alexander Sweetman (Flinders University)H-Index: 5
#2Leon Lack (Flinders University)H-Index: 38
Last. Jan RobinsonH-Index: 1
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Insomnia and obstructive sleep apnoea (OSA) frequently co-occur and may be causally related through sleep fragmentation and/or hyperarousal mechanisms. Previous studies suggest that OSA treatment can improve insomnia severity. However, the effect of insomnia treatment on OSA severity has not been investigated. We performed a randomised controlled trial to investigate the effect of cognitive behavioural therapy for insomnia (CBTi) on OSA severity, controlling for potential sleep-stage and posture...
1 CitationsSource
#1Jason C. Ong (NU: Northwestern University)H-Index: 23
#2Megan R. Crawford (University of Strathclyde)H-Index: 9
Last. Jack D. EdingerH-Index: 49
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STUDY OBJECTIVES: To investigate treatment models using cognitive-behavior therapy for insomnia (CBT-I) and positive airway pressure (PAP) for people with obstructive sleep apnea (OSA) and comorbid insomnia. METHODS: 121 adults with OSA and comorbid insomnia were randomized to receive CBT-I followed by PAP, CBT-I concurrent with PAP, or PAP only. PAP was delivered following standard clinical procedures for in-lab titration and home set-up and CBT-I was delivered in four individual sessions. The ...
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#1Seog Ju Kim (SMC: Samsung Medical Center)H-Index: 21
Source
#1Alexander Sweetman (Flinders University)H-Index: 5
#2R. Doug McEvoy (Flinders University)H-Index: 30
Last. Leon Lack (Flinders University)H-Index: 38
view all 14 authors...
STUDY OBJECTIVES: While cognitive and behavioral therapy for insomnia (CBTi) is an effective treatment in patients with co-morbid moderate and severe obstructive sleep apnea (OSA), there is concern that the bedtime restriction component of CBTi might dangerously exacerbate daytime sleepiness in such patients. We examined randomized controlled trial data to investigate the effect of OSA severity, and pre-treatment daytime sleepiness on week-to-week changes in daytime sleepiness and sleep paramete...
1 CitationsSource
#1Alexander Sweetman (Flinders University)H-Index: 5
#2Leon Lack (Flinders University)H-Index: 38
Last. Célyne H. Bastien (Laval University)H-Index: 27
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Co-morbid insomnia and sleep apnea (COMISA) is a highly prevalent and debilitating disorder, which results in additive impairments to patients’ sleep, daytime functioning, and quality of life, and complex diagnostic and treatment decisions for clinicians. Although the presence of COMISA was first recognized by Christian Guilleminault and colleagues in 1973, it received very little research attention for almost three decades, until the publication of two articles in 1999 and 2001 which collective...
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Last. Dirk A.A. Pevernagie (UGent: Ghent University)H-Index: 2
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Both obstructive sleep apnoea (OSA) and chronic insomnia disorder are highly prevalent in the general population. Whilst both disorders may occur together by mere coincidence, it appears that they share clinical features and that they may aggravate each other as a result of reciprocally adverse pathogenetic mechanisms. Comorbidity between chronic insomnia disorder and OSA is a clinically relevant condition that may confront practitioners with serious diagnostic and therapeutic challenges. Curren...
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