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Sweetman A, Lack L, Catcheside PG, Antic NA, Smith S, Chai-Coetzer CL, Douglas J, O'grady A, Dunn N, Robinson J, Paul D, Williamson P, McEvoy RD. 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. Sleep 2020; 42:5546131. [PMID: 31403168 DOI: 10.1093/sleep/zsz178] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 06/04/2019] [Indexed: 11/15/2022] Open
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.
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Affiliation(s)
- Alexander Sweetman
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, College of Medicine and Public Health, Flinders University of South Australia, Bedford Park, South Australia, Australia.,College of Education Psychology and Social Work, Flinders University, Bedford Park, South Australia, Australia
| | - Leon Lack
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, College of Medicine and Public Health, Flinders University of South Australia, Bedford Park, South Australia, Australia.,College of Education Psychology and Social Work, Flinders University, Bedford Park, South Australia, Australia
| | - Peter G Catcheside
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, College of Medicine and Public Health, Flinders University of South Australia, Bedford Park, South Australia, Australia
| | - Nick A Antic
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, College of Medicine and Public Health, Flinders University of South Australia, Bedford Park, South Australia, Australia.,Sleep Health Service, Repatriation General Hospital and Respiratory and Sleep Services, Southern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Simon Smith
- Institute for Social Science Research (ISSR), University of Queensland, Brisbane, Queensland, Australia
| | - Ching Li Chai-Coetzer
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, College of Medicine and Public Health, Flinders University of South Australia, Bedford Park, South Australia, Australia.,Sleep Health Service, Repatriation General Hospital and Respiratory and Sleep Services, Southern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - James Douglas
- Thoracic Program, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Amanda O'grady
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, College of Medicine and Public Health, Flinders University of South Australia, Bedford Park, South Australia, Australia
| | - Nicola Dunn
- Thoracic Program, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Jan Robinson
- Thoracic Program, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Denzil Paul
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, College of Medicine and Public Health, Flinders University of South Australia, Bedford Park, South Australia, Australia
| | - Paul Williamson
- College of Education Psychology and Social Work, Flinders University, Bedford Park, South Australia, Australia
| | - R Doug McEvoy
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, College of Medicine and Public Health, Flinders University of South Australia, Bedford Park, South Australia, Australia.,Sleep Health Service, Repatriation General Hospital and Respiratory and Sleep Services, Southern Adelaide Local Health Network, Adelaide, South Australia, Australia
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