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

Abstract

Study objectives: This study examines the impact of cognitive behavioral therapy for insomnia (CBT-I) and positive airway pressure (PAP) therapy for comorbid insomnia and sleep apnea on nocturnal sleep and daytime functioning.

Methods: A partial factorial design was used to examine treatment pathways with CBT-I and PAP and the relative benefits of each treatment. One hundred eighteen individuals with comorbid insomnia and sleep apnea 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. Participants were assessed at baseline, PAP titration, and 30 and 90 days after PAP initiation. Outcome measures included sleep diary- and actigraphy-measured sleep, Flinders Fatigue Scale, Epworth Sleepiness Scale, Functional Outcome of Sleep Questionnaire, and cognitive emotional measures.

Results: A main effect of time was found on diary-measured sleep parameters (decreased sleep onset latency and wake after sleep onset; increased total sleep time and sleep efficiency) and actigraphy-measured sleep parameters (decreased wake after sleep onset; increased sleep efficiency) and daytime functioning (reduced Epworth Sleepiness Scale, Flinders Fatigue Scale; increased Functional Outcome of Sleep Questionnaire) across all arms (all P < .05). Significant interactions and planned contrast comparisons revealed that CBT-I was superior to PAP and self-monitoring on reducing diary-measured sleep onset latency and wake after sleep onset and increasing sleep efficiency, as well as improving Functional Outcome of Sleep Questionnaire and Flinders Fatigue Scale compared to self-monitoring.

Conclusions: Improvements in sleep and daytime functioning were found with PAP alone or concomitant with CBT-I. However, more rapid effects were observed on self-reported sleep and daytime performance when receiving CBT-I regardless of when it was initiated. Therefore, concomitant treatment appears to be a favorable approach to accelerate treatment outcomes.

Clinical trial registration: Registry: ClinicalTrials.gov; Name: Multidisciplinary Approach to the Treatment of Insomnia and Comorbid Sleep Apnea (MATRICS); URL: https://ichgcp.net/clinical-trials-registry/NCT01785303; Identifier: NCT01785303.

Citation: Tu AY, Crawford MR, Dawson SC, et al. 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. J Clin Sleep Med. 2022;18(3):789-800.

Keywords: cognitive behavior therapy for insomnia; comorbid insomnia and sleep apnea; daytime functioning; positive airway pressure therapy; sleep.

Conflict of interest statement

All authors have seen and approved the manuscript. Work for this study was performed at Northwestern University Feinberg School of Medicine. This study was funded by the National Institutes of Health under grant award number R01HL114529. Spencer Dawson is on the advisory board of Better Sleep, Jason Ong receives salary from Nox Health, and Jack Edinger is a consultant for Somly. The study was conducted prior to these relationships and is not related to Better Sleep, Nox Health, or Somly. The other authors have no conflicts of interest relevant to this study.

© 2022 American Academy of Sleep Medicine.

Figures

Figure 1. CONSORT flowchart.

CBT-I = cognitive behavioral therapy for insomnia, CONSORT = Consolidated Standards of Reporting Trials, PAP = positive airway pressure.

Figure 2. Sleep diary- and actigraphy-measured total time in bed (TIB) from baseline to 90 days after PAP initiation (mean ± standard errors).

Arm A: Cognitive behavioral therapy for insomnia (CBT-I) in Phase I (Baseline to PAP Titration) followed by PAP in Phase II (PAP Titration to 90-day assessment); Arm B: self-monitoring in Phase I followed by CBT-I + PAP in Phase II; Arm C: self-monitoring in Phase I followed by PAP in Phase II. (A) Depicts the reductions in self-reported TIB in Arm A and B during CBT-I delivery, and (B) depicts a similar pattern of changes in actigraphy-measured TIB, both indicating evidence of participants’ adherence to the sleep restriction protocol in CBT-I. PAP = positive airway pressure.

Figure 3. Sleep diary-measured sleep efficiency (SE) from baseline to 90 days after PAP initiation (mean ± standard errors).

Arm A: Cognitive behavioral therapy for insomnia (CBT-I) followed by PAP; Arm B: self-monitoring followed by CBT-I + PAP; Arm C: self-monitoring followed by PAP. PAP = positive airway pressure.

Figure 4. Functional Outcomes of Sleep Questionnaire (FOSQ) total score from baseline to 90 days after PAP initiation (mean ± standard errors).

Higher scores represent less difficulties in performing daily activities. Arm A: Cognitive behavioral therapy for insomnia (CBT-I) followed by PAP; Arm B: self-monitoring followed by CBT-I + PAP; Arm C: self-monitoring followed by PAP. PAP = positive airway pressure.