A randomized controlled trial of CBT-I and PAP for obstructive sleep apnea and comorbid insomnia: effects on nocturnal sleep and daytime performance

Alice Y. Tu, Megan R. Crawford, Spencer C. Dawson, Louis F. Fogg, Arlener D. Turner, James K. Wyatt, Maria I. Crisostomo, Bantu S. Chhangani, Clete A. Kushida, Jack D. Edinger, Sabra M. Abbott, Roneil G. Malkani, Hrayr P. Attarian, Phyllis C. Zee, Jason C. Ong

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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 (COMISA) on nocturnal sleep and daytime functioning. A partial factorial design was used to examine treatment pathways with CBT-I and PAP and the relative benefits of each treatment. 118 individuals with COMISA 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(FFS), Epworth Sleepiness Scale(ESS), Functional Outcome of Sleep Questionnaire(FOSQ), and cognitive-emotional measures. A main effect of time was found on diary-measured sleep parameter (decreased sleep onset latency[SOL] and wake after sleep onset[WASO]; increased total sleep time[TST] and sleep efficiency[SE]) and actigraphy-measured sleep parameter (decreased WASO; increased SE) and daytime functioning (reduced ESS, FFS; increased FOSQ) across all arms (all p< 0.05). Significant interactions and planned contrast comparisons revealed that CBT-I was superior to PAP and self-monitoring on reducing diary-measured SOL and WASO and increasing SE; as well as improving FOSQ and FFS compared to self-monitoring. Improvements in sleep and daytime functioning were found with PAP alone or concomitant with CBT-I. However, more rapid effects were observed on subjective 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. Registry: ClinicalTtrials.gov; Identifier: NCT01785303.
Original languageEnglish
Pages (from-to)789-800
Number of pages12
JournalJournal of Clinical Sleep Medicine
Issue number3
Early online date15 Oct 2021
Publication statusPublished - 1 Mar 2022


  • clinical neurology
  • neurology
  • pulmonary and respiratory medicine
  • comorbid insomnia
  • sleep apnea
  • cognitive behavior therapy
  • CBT
  • positive airway pressure therapy
  • sleep
  • daytime functioning


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