The effect of cognitive and behavioral therapy for insomnia on week-to-week changes in sleepiness and sleep parameters in insomnia patients with co-morbid moderate and severe sleep apnea: A randomized controlled trial

Alexander Sweetman, R Doug McEvoy, Simon Smith, Peter Catcheside, Nicholas Antic, Ching Chai-Coetzer, James Douglas, Mandy O'Grady, Nicola Dunn, Jan Robinson, Denzil Paul , Paul Williamson, Leon Lack

Research output: Contribution to journalArticle

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.

Keywords:
insomnia, cognitive behavioral therapy for insomnia, sleep restriction therapy, co-morbid insomnia, obstructive sleep apnea, COMISA, excessive daytime sleepiness
Original languageEnglish
Pages (from-to)1-13
Number of pages13
JournalSLEEP
Early online date12 Jan 2020
DOIs
Publication statusE-pub ahead of print - 12 Jan 2020

Keywords

  • cognitive therapy
  • behavioral therapy
  • insomnia
  • sleep
  • sleep patterns
  • sleep apnea

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