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The effect of cognitive and behavioral therapy for insomnia on week-to-week changes in sleepiness and sleep parameters in patients with comorbid insomnia and sleep apnea: a randomized controlled trial

Published on Jan 12, 2020in Sleep4.571
· DOI :10.1093/SLEEP/ZSAA002
Alexander Sweetman5
Estimated H-index: 5
(Flinders University),
R. Doug McEvoy30
Estimated H-index: 30
(Flinders University)
+ 11 AuthorsLeon Lack38
Estimated H-index: 38
(Flinders University)
Abstract
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 parameters during CBTi and no-treatment control. METHODS: 145 patients with untreated physician-diagnosed OSA (Apnea-hypopnea index>/=15) and psychologist-diagnosed insomnia (ICSD-3) were randomized to a four-week CBTi program (n=72), or no-treatment control (n=73). The Epworth sleepiness scale (ESS) and sleep diaries were completed during pre-treatment, weekly CBTi sessions, and post-treatment. Effects of OSA-severity, pre-treatment daytime sleepiness, and intervention-group, on weekly-changes in daytime sleepiness and sleep parameters were investigated. RESULTS: The CBTi group reported a 15% increase in ESS scores following the first week of bedtime restriction (M change=1.3 points, 95%CI=0.1-2.5, p=0.031, Cohen's d=0.27) which immediately returned to pre-treatment levels for all subsequent weeks, while sleep parameters gradually improved throughout CBTi. There were no differences in changes in daytime sleepiness during treatment between CBTi and control groups, or OSA-severity groups. Higher pre-treatment ESS scores were associated with a greater ESS reduction during CBTi. CONCLUSION: CBTi appears to be a safe and effective treatment in the presence of co-morbid moderate and severe OSA. Nevertheless, COMISA patients treated with CBTi should be monitored closely for increased daytime sleepiness during the initial weeks of bedtime restriction therapy.
  • References (49)
  • Citations (1)
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References49
Newest
#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 13 authors...
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 ...
7 CitationsSource
#1Alexander Sweetman (Flinders University)H-Index: 5
#2Leon Lack (Flinders University)H-Index: 38
Last. Doug McEvoy (Flinders University)H-Index: 3
view all 3 authors...
CITATIONSweetman A, Lack L, McEvoy D. Refining the measurement of insomnia in patients with obstructive sleep apnea. J Clin Sleep Med. 2019;15(12):1717–1719.
2 CitationsSource
#1Alexander Sweetman (Flinders University)H-Index: 5
#2Leon Lack (Flinders University)H-Index: 38
Last. Célyne H. Bastien (Laval University)H-Index: 27
view all 3 authors...
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...
8 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...
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#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
#1Leon Lack (Flinders University)H-Index: 38
#2Alexander Sweetman (Flinders University)H-Index: 5
: Insomnia is often comorbid with obstructive sleep apnea. It reduces positive airway pressure (PAP) therapy acceptance and adherence. Comorbid patients show greater daytime impairments and poorer health outcomes. The insomnia often goes undiagnosed, undertreated, or untreated. Pharmacotherapy is not recommended for long-term treatment. Although care should be taken administering behavioral therapies to patients with elevated sleepiness, cognitive behavior therapy for insomnia (CBTi) is an effec...
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#1Constance H. Fung (UCLA: University of California, Los Angeles)H-Index: 18
#2Jennifer L. Martin (UCLA: University of California, Los Angeles)H-Index: 43
Last. Cathy A. AlessiH-Index: 42
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The aims of the study were to determine whether mild, occult sleep-disordered breathing (SDB) moderates the efficacy of cognitive behavioral therapy for insomnia (CBTI) in older adults and to explore whether CBTI reduces the number of patients eligible for positive airway pressure (PAP) therapy.Data were analyzed for 134 adults 60 years or older with insomnia and apnea-hypopnea index (AHI) of less than 15 who were randomized to a larger study of CBTI versus a sleep education control. Sleep outco...
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#1Megan R. Crawford (Rush University Medical Center)H-Index: 9
#2Arlener D. Turner (Rush University Medical Center)H-Index: 8
Last. Jason C. Ong (Rush University Medical Center)H-Index: 23
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Chronic insomnia disorder is a prevalent condition and a significant proportion of these individuals also have obstructive sleep apnea (OSA). These two sleep disorders have distinct pathophysiology and are managed with different treatment approaches. High comorbidity rates have been a catalyst for emerging studies examining multidisciplinary treatment for OSA comorbid with insomnia disorder. In this article, we describe a randomized clinical trial of cognitive behavioral treatment for insomnia (...
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#1Erla Bjornsdottir (University of Iceland)H-Index: 10
#2Brendan T. Keenan (UPenn: University of Pennsylvania)H-Index: 18
Last. Bryndis Benediktsdottir (University of Iceland)H-Index: 28
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Obstructive sleep apnea (OSA) leads to recurrent arousals from sleep, oxygen desaturations, daytime sleepiness and fatigue. This can have an adverse impact on quality of life. The aims of this study were to compare: 1) quality of life between the general population and untreated OSA patients; and 2) changes of quality of life among OSA patients after two years of positive airway pressure (PAP) treatment between adherent patients and non-users. Propensity score methodologies were used in order to...
30 CitationsSource
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Newest
#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...
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