Comorbid Insomnia and Sleep Apnea

Comorbid Insomnia and Sleep Apnea: From Research to Clinical Practice

Comorbid insomnia and sleep apnea (COMISA) represents a highly prevalent and clinically significant overlap between the two most common sleep disorders: insomnia and obstructive sleep apnea (OSA). COMISA is associated with greater impairment in sleep, daytime functioning, and physical and mental health compared with insomnia or OSA alone. Despite its prevalence, COMISA has historically been underrecognized, partially due to the conflicting symptoms of insomnia (e.g., hyperarousal and sleeplessness) and OSA (e.g., sleep fragmentation and excessive daytime sleepiness). Recent research highlights that COMISA is not merely the coexistence of insomnia and OSA but may involve unique pathophysiological interactions and clinical phenotypes. This review explores the epidemiology, mechanisms, and clinical manifestations of COMISA. We examine insomnia as a potential extension of OSA, where repeated apneic events lead to conditioned hyperarousal, as well as OSA as an extension of chronic insomnia through mechanisms such as autonomic dysregulation and respiratory instability. Furthermore, we consider COMISA as a distinct entity, characterized by bidirectional interactions between the two conditions that exacerbate their clinical and physiological burden. Key challenges in diagnosing COMISA are discussed, including overlapping symptoms and limitations in current assessment tools. Emerging evidence suggests that COMISA is associated with increased cardiovascular and metabolic risks, greater mental health burden, and reduced treatment adherence to positive airway pressure (PAP) therapy. Advances in tailored therapeutic approaches, including combined cognitive-behavioral therapy for insomnia and OSA management strategies, are highlighted as promising avenues to improve outcomes. Understanding COMISA as a multidimensional condition with diverse phenotypes and mechanisms underscores the need for integrated diagnostic frameworks and personalized treatment strategies to optimize patient care. Further research into its unique features and long-term consequences is critical to advancing clinical practice in sleep and respiratory medicine.

Prediction of non-responders to oral appliance treatment of obstructive sleep apnea: a pilot study

PURPOSE

Several clinically available variables have been identified as predictors of non-response to oral appliance (OA) treatment, including endotypical traits such as severe upper airway collapsibility, unstable ventilatory control, and low arousal threshold. This study aimed to identify potential predictors of non-response to OA treatment in patients with OSA non-adherent to treatment with positive airway pressure.

METHODS

Patients in this study were initially treated with OAs with and without elastic bands in a crossover design. Subsequently, each patient selected their preferred treatment modality for continued therapy based on subjective preferences. The chosen OA treatment. The chosen OA treatment modality was titrated optimally based on reduction of REI. Patients not reaching > 50% reduction of REI from baseline were classified as non-responders. Statistical analyses were conducted using Student's t-test and Pearson's chi-squared test to assess differences in baseline variables between responders and non-responders, and logistic regression analyses were performed to investigate variables associated with not responding to OA treatment.

RESULTS

Overall, 63.2% (n = 36) of the patients were responders to OA treatment following titration. Smaller distance from habitual bite position to maximal retruded position (Odds ratio: 0.28, p = 0.016), positional OSA (Odds ratio: 0.94, p = 0.024) and a higher number of the endotypical OSA traits severe collapsibility, high loop gain and low arousal threshold (Odds ratio: 7.41, p = 0.038), were found to predict non-response to OA treatment.

CONCLUSION

These novel findings suggest that severe upper airway collapsibility, high loop gain and low arousal threshold, identified through clinically available variables, appear to be important predictors of non-response to OA treatment, along with short distance from habitual bite position to maximal retruded position and positional OSA.

TRIAL REGISTRATION NUMBER

NCT05987618 (clinicaltrials.gov).

Impact of Preoperative Daytime Sleepiness and Insomnia on Therapy Adherence and Neurostimulation Amplitude in Unilateral Hypoglossal Nerve Stimulation

Introduction

Average adherence to hypoglossal nerve stimulation (HGNS) therapy is more than 5 h/night. Reported data on HGNS therapy adherence is often based on studies that performed in-lab titration of the neurostimulation parameters and may therefore not represent real-world therapy outcomes. Adherence to HGNS therapy is a major determinant of success of this kind of therapy. Factors with the potential to influence adherence to HGNS therapy should be further elucidated. The aims of this study were to investigate 1) details regarding therapy adherence under HGNS therapy and 2) the possible association between age, insomnia, daytime sleepiness, polysomnography (PSG)-based metrics, neurostimulation parameters and HGNS-therapy adherence.

Methods

Forty-three consecutive patients with detailed information about therapy adherence time were included. About 225 ± 191 days after implantation, a PSG without any in-lab titration was performed. Adherence was assessed by interrogating the impulse generator's data at that time. Patient-reported insomnia was assessed using the insomnia severity index (ISI) and the Epworth Sleepiness scale (ESS) was used to assess daytime sleepiness before and after HGNS treatment.

Results

An increased adherence in a real-world setting with 48.72 ± 14.74 hours per week (6.96 hours per night) was found. A strong negative correlation between preoperative ESS score and adherence time (r = - 0.43; p<0.005) was found. Neither pre-operative insomnia nor sleepiness had any impact on neurostimulation amplitude. A positive association between preoperative age and therapeutic amplitude levels could be shown.

Discussion

In this cohort, average adherence was much higher than previously reported. We provide evidence that pre-operative excessive daytime sleepiness may seriously impair adherence to HGNS therapy.

New management pathways for follow-up of CPAP-treated sleep apnoea patients including digital medicine and multimodal telemonitoring

BACKGROUND

The ever-increasing number of patients diagnosed with obstructive sleep apnoea (OSA) and treated by long-term continuous positive airway pressure (CPAP) overstretches conventional follow-up pathways. New approaches to the management of CPAP-treated patient follow-up are needed to strike a balance between remote monitoring through digital technologies and in-person patient-healthcare-professional contacts. Focusing on the reshaping of the management of care pathways of CPAP-treated patients, with a specific focus on telemonitoring platforms, we aimed to review the evidence on how digital medicine and artificial intelligence (AI) tools are facilitating patient phenotyping and triage, risk stratification and the allocation of resources between the various healthcare professionals for an optimal follow-up of CPAP-treated patients.

PHENOTYPING

OSA is a heterogeneous condition with diverse phenotypes differing in symptoms, comorbidities, demographics, lifestyle and socioeconomic context. Different phenotypes are associated with different CPAP adherence patterns and differing long-term prognosis. This diversity demands greater plurality in management pathways with different types and levels of support to ensure treatment adherence and risk reduction for patients while easing the burden on health services. In multidimensional phenotyping, we discuss alternatives to the apnoea hypopnoea index (AHI) as a measure of OSA severity. Then we consider risk stratification taking advantage of the wealth of CPAP monitoring data already available in databases that can now be exploited using AI and machine learning to direct (stratify) patients into appropriate follow-up management pathways.

INTEGRATED CARE CLINICS FOR HIGH-RISK PATIENTS

We look at the role of integrated OSA care clinics particularly for the management of high-risk patients with low adherence and progression of comorbidities. Here, multidisciplinary teams might propose comorbidity management, and the use of connected wearable devices for long-term monitoring of physical activity, along with remote CPAP monitoring.

REMOTE MANAGEMENT PATHWAYS

The pros and cons of remote management pathways to replace in-person follow-up visits are considered, including the need to re-evaluate CPAP-device reimbursement policies in some countries. While remote CPAP monitoring has become the cornerstone of follow-up providing information on adherence and efficacy, the processing of alerts needs to be improved, particularly regarding mask changes and early detection of CPAP failures.

CHALLENGES

The implementation of CPAP monitoring alone, as well as its extension to multimodal monitoring, can present challenges that remain to be addressed (eg, access to digital care). The extent and components of remote follow-up must be adapted to each specific OSA phenotype. Finally, we give examples of certain patient phenotypes (eg, comorbid insomnia with OSA) with specific follow-up requirements, for which remote (even multimodal) monitoring alone has limitations and the intervention of both sleep specialists and/or their colleagues from other disciplines is needed.

CONCLUSION

Appropriately tailored combined digital and in-person CPAP follow-up pathways would present advantages both for patients with OSA and healthcare services.

Co-morbid Insomnia and Sleep Apnea (COMISA) in a large sample of Iranian: prevalence and associations in a sleep clinic population

BACKGROUND

Sleep apnea (SA) and insomnia (INS) are prevalent sleep disorders among referrals to sleep clinics. People with comorbid insomnia and sleep apnea (COMISA) suffer both disorders simultaneously. The epidemiology of COMISA is not well known in the Middle East including Iran. We hypothesized that COMISA is prevalent in metropolitan sleep clinic cohorts in Iran.

METHOD

The records of patients aged < 95 years referred to sleep disorders centers in four large metropolitan areas including Kermanshah, Tabriz, Shiraz, and Ahvaz were examined. Polysomnography (PSG) was performed in all these patients in specialized centers and the results were scored by a trained technician and interpreted by a sleep specialist. SA was defined as an Apnea-Hypopnea Index (AHI ≥ 5), INS was defined by psychiatrists according to self-report and clinical interviews, and COMISA was defined if both disorders were present. Participants with neither condition were included in as comparator group. One-way ANOVAs, correlation, and linear/logistic regression analyses were used.

RESULTS

This study included 1807 patients (Mean age 49.3, SE ± 13.7; 38.8% Female). Comparator, INS, SA and COMISA made up 7.2%, 16%, 50.2% and 26.6% of the sample, respectively. Logistic regression analyses showed that male gender, older age, and increasing neck circumference, but not BMI, were associated with COMISA. Epworth Sleepiness Scale scores were lower in INS (5.39 ± 5.78) compared to the other three groups.

CONCLUSION

COMISA is a prevalent condition in metropolitan sleep centers in Iran among participants referred to sleep centers. The data showed that male gender and age were associated significantly with COMISA.

Effects of nurse-led brief behavioral treatment for insomnia in adults: a randomized controlled trial

STUDY OBJECTIVES

We examined the effects of nurse-led brief behavioral treatment for insomnia (BBTI) on insomnia severity, sleep status, daytime function, quality of life, psychological distress levels, treatment response, and insomnia remission in young and middle-aged Asian adults with insomnia symptoms.

METHODS

This 2-parallel, randomized controlled trial recruited 42 participants with insomnia symptoms randomly allocated to the nurse-led BBTI group or sleep hygiene group. The outcome measurements included the Insomnia Severity Index, sleep diary, Pittsburgh Sleep Quality Index, Epworth Sleepiness Scale, Brief Fatigue Inventory, RAND-36 Health Status Inventory, and the Depression, Anxiety, and Stress Scale-21. The measurement time points included baseline, the end of each week of the intervention period, and 1-month follow-up.

RESULTS

Compared with the sleep hygiene group, participants in the BBTI group had significantly improved insomnia severity, sleep onset latency, sleep efficiency, sleep quality, daytime sleepiness, and the mental components of quality of life after completing nurse-led BBTI immediately and 1 month later (P < .05). In addition, 52.4% and 71.4% of the participants achieved remission after completing nurse-led BBTI immediately and 1 month later, which was significantly higher than in the sleep hygiene group (14.3%, P = .02; 14.3%, P < .001, respectively).

CONCLUSIONS

We suggested the relative effects of BBTI on declined insomnia severity and improved sleep status among young and middle-aged Asian adults with insomnia symptoms and confirmed the benefits of nurse-led BBTI in alleviating insomnia. Nurses should incorporate BBTI into insomnia care further to enhance the daytime function and quality of life of the population with insomnia symptoms.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Effects of Nurse-led Brief Behavioral Treatment for Insomnia: A Feasibility Randomized Controlled Trial; URL: https://clinicaltrials.gov/study/NCT05310136; Identifier: NCT05310136.

CITATION

Chang K-M, Lin C-J, Jan Y-W, et al. Effects of nurse-led brief behavioral treatment for insomnia in adults: a randomized controlled trial. J Clin Sleep Med. 2024;20(11):1763-1772.

Real-world data on polysomnography- and patient-reported outcomes in hypoglossal nerve stimulation and auto-titrating positive airway pressure therapy for obstructive sleep apnea

BACKGROUND

Few data are available comparing first-line positive airway pressure (PAP) therapy of obstructive sleep apnea (OSA), especially auto-adjusting PAP (aPAP), with second-line hypoglossal nerve stimulation (HGNS) therapy. The aim of this study was to directly compare these therapeutic options by standard polysomnography (PSG)-related parameters and patient-reported outcomes in comparable groups.

METHODS

20 patients (aged 57.30 ± 8.56 years; 6 female) were included in the HGNS and 35 patients (aged 56.83 ± 9.20 years; 9 female) were included in the aPAP group. In both groups participants had to fit the current guideline criteria for HGNS treatment. Groups were compared by analysis of covariance (ANCOVA) using inverse propensity score weighting.

RESULTS

Propensity scores did not differ between groups. Pre-therapeutic AHI (HGNS: 40.22 ± 12.78/h; aPAP: 39.23 ± 12.33/h) and ODI (HGNS: 37.9 ± 14.7/h, aPAP: 34.58 ± 14.74/h) were comparable between the groups. After 413.6 ± 116.66 days (HGNS) and 162.09 ± 140.58 days (aPAP) of treatment AHI (HGNS: 30.22 ± 17.65/h, aPAP group: 4.71 ± 3.42/h; p < 0.001) was significantly higher in the HGNS group compared to the aPAP group. However, epworth sleepiness scale (ESS) was post-interventionally significantly lower in the HGNS group compared to the aPAP group (pretherapeutic: HGNS: 13.32 ± 5.81 points, aPAP: 9.09 ± 4.71 points; posttherapeutic: HGNS: 7.17 ± 5.06 points; aPAP: 8.38 ± 5.41 points; p < 0.01).

CONCLUSION

These are novel real-world data. More research on the key parameters regarding titration of the HGNS neurostimulation parameter tuning and on the impact of factors influencing HGNS adherence is needed.

The Complex Relationship between Neuromodulators, Circadian Rhythms, and Insomnia in Patients with Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) has been linked to disruptions in circadian rhythm and neurotrophin (NFT) signaling. This study explored the link between neuromodulators, chronotype, and insomnia in OSA. The participants (n = 166) underwent polysomnography (PSG) before being categorized into either the control or the OSA group. The following questionnaires were completed: Insomnia Severity Index (ISI), Epworth Sleepiness Scale, Chronotype Questionnaire (morningness-eveningness (ME), and subjective amplitude (AM). Blood samples were collected post-PSG for protein level assessment using ELISA kits for brain-derived neurotrophic factor (BDNF), proBDNF, glial-cell-line-derived neurotrophic factor, NFT3, and NFT4. Gene expression was analyzed utilizing qRT-PCR. No significant differences were found in neuromodulator levels between OSA patients and controls. The controls with insomnia exhibited elevated neuromodulator gene expression (p < 0.05). In the non-insomnia individuals, BDNF and NTF3 expression was increased in the OSA group compared to controls (p = 0.007 for both); there were no significant differences between the insomnia groups. The ISI scores positively correlated with all gene expressions in both groups, except for NTF4 in OSA (R = 0.127, p = 0.172). AM and ME were predicting factors for the ISI score and clinically significant insomnia (p < 0.05 for both groups). Compromised compensatory mechanisms in OSA may exacerbate insomnia. The correlation between chronotype and NFT expression highlights the role of circadian misalignments in sleep disruptions.

A Pilot Randomized Trial of Combined Cognitive-Behavioral Therapy and Exercise Training Versus Exercise Training Alone for the Management of Chronic Insomnia in Obstructive Sleep Apnea

Insomnia treatment among individuals with comorbid insomnia and obstructive sleep apnea is suboptimal. In a pilot randomized controlled trial, 19 individuals with comorbid insomnia and obstructive sleep apnea were allocated to one of two arms: EX + EX, consisting of two 8-week phases of exercise training (EX), or RE + CBTiEX, encompassing 8 weeks of relaxation training (RE) followed by 8 weeks of combined cognitive-behavioral therapy and exercise (CBTiEX). Outcomes included Insomnia Severity Index (ISI), polysomnography, and cardiorespiratory fitness measures. A mixed-model analysis of variance revealed a Group × Time interaction on peak oxygen consumption change, F(1, 14) = 10.1, p = .007, and EX increased peak oxygen consumption (p = .03, g' = -0.41) and reduced ISI (p = .001, g' = 0.82) compared with RE (p = .49, g = 0.16) post-8 weeks. Post-16 weeks, there was a significant Group × Time interaction (p = .014) driven by RE + CBTiEX yielding a larger improvement in ISI (p = .023, g' = 1.48) than EX + EX (p = .88, g' < 0.1). Objective sleep was unchanged. This study showed promising effects of regular EX alone and combined with cognitive-behavioral therapy for insomnia on ISI in comorbid insomnia and obstructive sleep apnea.

Cardiovascular Outcome in Patients with Major Depression: Role of Obstructive Sleep Apnea Syndrome, Insomnia Disorder, and COMISA

In this study, the 10-year cardiovascular risk associated with comorbid sleep disorders (insomnia disorder, obstructive sleep apnea syndrome, and COMISA [comorbid insomnia and sleep apnea]) was investigated for patients with major depression. To enable our analysis, 607 patients with major depression were selected from the data register of the Sleep Unit. High 10-year cardiovascular risk was considered present when the Framingham Risk Score was ≥10%. The 10-year cardiovascular risk associated with comorbid sleep disorders has been assessed using logistic regression analyzes. High 10-year cardiovascular risk is significant (40.4%) in patients with major depression. After successive introduction of the different confounders, multivariate logistic regressions showed that for patients with major depression high 10-year cardiovascular risk was significantly associated with COMISA but was not significantly associated with insomnia disorder or obstructive sleep apnea syndrome alone. Thus, these results highlight the existence of a negative synergistic action between insomnia disorder and obstructive sleep apnea syndrome on the 10-year cardiovascular risk in patients with major depression, which demonstrates the importance of researching and treating COMISA to improve the prognosis of this specific population subgroup characterized by higher cardiovascular morbidity and mortality.

Respiratory muscle training for obstructive sleep apnea: Systematic review and meta-analysis

Obstructive sleep apnea is the most common sleep disorder. This review aims to evaluate the effectiveness and safety of respiratory muscle training in the treatment of patients with obstructive sleep apnea. The study protocol was registered in Prospero Platform (CRD42018096980). We performed searches in the main databases: Medical Literature Analysis and Retrieval System Online (MEDLINE) via Pubmed; Excerpta Medica dataBASE (Embase) via Elsevier; Cochrane Central Register of Controlled Trials (CENTRAL) via Cochrane Library; Latin American and Caribbean Literature on Health Sciences (LILACS) through the Portal of the Virtual Health Library and Physiotherapy Evidence Database (PEDro) for all randomised-controlled trials published before July 2022. The randomised-controlled trials were assessed for risk of bias and certainty of evidence. Thirteen randomised-controlled trials were included. All studies had an overall high risk of bias. Inspiratory muscle training probably improves systolic blood pressure and sleepiness when compared with sham. However, inspiratory muscle training probably does not improve diastolic blood pressure and maximum expiratory pressure, and may not be superior to sham for apnea-hypopnea index, forced expiratory volume in 1 s, forced vital capacity, sleep quality and quality of life. In addition, it is uncertain whether there is any effect of inspiratory muscle training on maximum inspiratory pressure and physical capacity. Inspiratory muscle training may also improve maximum inspiratory pressure and maximum expiratory pressure compared with oropharyngeal exercises. However, it may not be superior for apnea-hypopnea index, sleep quality, sleepiness, quality of life and functional capacity. When associated with physical exercise, inspiratory muscle training may not be superior to physical exercise alone for maximum inspiratory pressure, maximum expiratory pressure, systolic and diastolic blood pressure, and functional capacity. At the same time, when associated with cardiac rehabilitation exercises, inspiratory muscle training may reduce apnea-hypopnea index, improve inspiratory muscle strength, sleepiness and sleep quality compared with cardiac rehabilitation alone. However, it may not be superior for improving quality of life. Regarding expiratory muscle training, it may improve expiratory muscle strength and sleep quality, but not sleepiness when compared with sham. The evidence on the effects of expiratory muscle training in apnea-hypopnea index is very uncertain.

Focus Group Study of Heart Failure Nurses' Perceptions of the Feasibility of Cognitive Behavioral Therapy for Insomnia

BACKGROUND

People with heart failure (HF) often report insomnia with daytime consequences, including fatigue and decreased functional performance. Cognitive behavioral therapy for insomnia is an efficacious treatment, but few have access because of a shortage of trained sleep specialists. Access may be improved by offering it where people with HF receive care.

OBJECTIVES

The purpose of this study was to explore the perceptions of nurses who specialize in HF regarding the value of cognitive behavioral therapy for insomnia to their patients, the feasibility of offering it in HF clinical settings, its delivery by nurses, and preferences for modes of delivery.

METHODS

We used a descriptive qualitative study design. We recruited focus group participants via e-mail to American Association of Heart Failure Nurses members and through requests for nurse collaborators to distribute within their networks. We conducted focus groups via Zoom. After describing cognitive behavioral therapy for insomnia and its efficacy for people with HF, we elicited perceptions about its value if provided in the HF outpatient clinical setting, facilitators and barriers to implementation, and other ways to increase access. We audio-recorded and transcribed the discussions. Two researchers coded the data and performed thematic analysis.

RESULTS

Four focus groups included 23 registered nurses and advanced practice nurses employed in outpatient HF clinics. We identified five themes: "Insomnia Overlooked," "Cognitive Behavioral Therapy for Insomnia Works," "Nurses' Role," "Barriers and Supports," and "Modes of Delivery." Nurses endorsed the importance of insomnia to people with HF and the value of providing cognitive behavioral therapy. They expressed interest in evaluating and addressing sleep, the need for increased resources to address it, and multiple modes of delivery. All nurses believed they had a role in promoting sleep health but differed in their views about providing cognitive behavioral therapy for insomnia.

DISCUSSION

Nurses specializing in HF support the implementation of cognitive behavioral therapy for insomnia. Implementation studies are needed to identify effective methods to increase access to this efficacious treatment in outpatient HF clinical settings, including support and training for nurses who are interested and able to deliver it.

[Results of a pilot study of the structure and evaluation of the therapy for chronic sleep disorders in comorbid patients with chronic cerebral ischemia]

OBJECTIVE

To evaluate the effect of the drug Cortexin on the clinical course and treatment of comorbid insomnia.

MATERIAL AND METHODS

The study included 50 patients, average age 50.4±2.26 years, with CHI stage 1-2. with concomitant diseases arterial hypertension, atherosclerosis, diabetes mellitus (study CHRONAS). All patients were examined on the day of treatment, 11-15 days and 30-31 days after the end of therapy. At all visits, complaints, neurological status, and changes in physiological and laboratory parameters were assessed. The condition was assessed using the following scales: mental status assessment (MMSE), quality of life questionnaire (EQ-5D), assessment of general health, Pittsburgh Sleep Quality Index (PSQI), Epworth daytime sleepiness assessment, hospital anxiety and depression (HADS)).: Patients with additional diabetic polyneuropathy were assessed using the Central Sensitization Inventory (CSI).

RESULTS

A high percentage of the prevalence of comorbid insomnia in patients was revealed. The structure of sleep disturbances in patients with chronic cerebral ischemia consisted of disturbances in sleep duration, difficulty falling asleep, frequent awakenings at night, and daytime sleepiness. After treatment, there was a regression of the main complaints, the severity of symptoms, including anxiety and depression, decreased, and a significant stabilization of cognitive status was observed. The positive dynamics persisted 1 month after the end of therapy. An additional normalizing effect of the drug on a number of biochemical parameters was revealed. Clinical dynamics were recorded already by the 11-15th day of treatment and persisted for up to 1 month. During observation, no patient had adverse drug interactions with other drugs (hypotensives, antiplatelet agents, statins).

CONCLUSIONS

The clinical effectiveness of the drug Cortexin has been proven for all types of sleep disorders. The clinical effectiveness of the drug Cortexin at a dose of 10 mg IM for 10 days has been proven in patients with chronic sleep disorders due to CHI.

Predictors of cognitive behavioral therapy for insomnia (CBT-I) effects in insomnia with major depressive episode

Insomnia plays a critical role in the onset and maintenance of Major Depressive Episode (MDE). Cognitive behavioral therapy for insomnia (CBT-I) can successfully improve the sleep of patients with insomnia and MDE. Nonetheless, the factors influencing CBT-I's effects in MDE remain uncertain. This study aimed to identify predictors of insomnia improvement following CBT-I, as well as predictors of insomnia response, remission in patients with MDE and specific insomnia subtypes. Initially, we compared a 4-session weekly CBT-I treatment to baseline sleep education (SE) in a control group. This confirmed CBT-I's positive effects and the need to explore predictive factors. Notably, treatment-resistant depression (TRD) predicted reduced insomnia severity with CBT-I. Patients exhibiting seasonal fluctuations in depressive symptoms and sleep patterns throughout the year, or having daytime dysfunction, experienced enhanced CBT-I efficacy, especially for early awakenings insomnia. Conversely, shorter sleep duration predicted a less favorable response to CBT-I, less improvement in daytime dysfunction and sleep disturbance worries. Additionally, MDE with suicide attempts predicted a poorer improvement of daytime dysfunction. Further research is essential to comprehensively grasp the mechanisms behind CBT-I's heightened effectiveness in MDE patients with TRD and seasonal fluctuations.

Pharmacological management of co-morbid obstructive sleep apnoea and insomnia

INTRODUCTION

Clinical presentation of both insomnia and obstructive sleep apnea (COMISA) is common. Approximately 30% of clinical cohorts with OSA have insomnia symptoms and vice versa. The underlying pathophysiology of COMISA is multifactorial. This poses a complex clinical challenge. Currently, there are no clinical guidelines or recommendations outside of continuous positive airway pressure (CPAP) therapy and cognitive behavioral therapy for insomnia (CBTi). Clinically translatable precision medicine approaches to characterize individual causes or endotypes may help optimize future pharmacological management of COMISA.

AREAS COVERED

This review article provides an up-to-date account of COMISA and its consequences, the underlying pathophysiology of sleep apnea, insomnia and COMISA, current treatment approaches and limitations, pharmacotherapy targets and future priorities.

EXPERT OPINION

There are multiple promising emerging therapies, but clinical trial data specifically in COMISA populations are lacking. This is a priority for future investigation to inform development of evidence-based guidelines. Pharmacotherapies, particularly for insomnia, do not target the underlying causes of the disorder thus, are indicated for short-term use only and should remain second line. Future multidisciplinary research should be directed toward the multifactorial nature of COMISA and the challenges of adapting COMISA treatment in clinical practice and overcoming the practical barriers that health-care providers and consumers encounter.

Neurocognitive functioning in comorbid insomnia and sleep apnea patients is better after positive airway pressure therapy, but worse after cognitive behavioral therapy for insomnia: exploratory analysis of cognitive outcomes from the Multidisciplinary Approach to the Treatment of Insomnia and Comorbid Sleep Apnea study

STUDY OBJECTIVES

Neurocognitive impairments in comorbid insomnia and sleep apnea (COMISA) are not well documented. We explored neurocognitive functioning and treatment effects in individuals with COMISA as an ancillary study to a randomized clinical trial.

METHODS

Participants with COMISA (n = 45; 51.1% female; mean age = 52.07 ± 13.29 years), from a 3-arm randomized clinical trial combining cognitive behavioral therapy for insomnia (CBT-I) and positive airway pressure (PAP) concurrently (CBT-I+PAP) or sequentially, completed neurocognitive testing at baseline, and post-treatment. Using Bayesian linear mixed models, we estimated effects of CBT-I, PAP, or CBT-I+PAP, compared to baseline, and CBT-I+PAP compared to PAP on 12 metrics across five cognitive domains.

RESULTS

This COMISA sample had worse neurocognitive performance at baseline than reported for insomnia, sleep apnea, and controls in the literature, though short-term memory and psychomotor speed performance appears intact. When comparing PAP to baseline, performance on all measures was better after treatment. Performance after CBT-I was worse compared to baseline, and only performance in attention/vigilance, executive functioning via Stroop interference and verbal memory was better with moderate-high effect sizes and moderate probability of superiority (61-83). Comparisons of CBT-I+PAP to baseline generated results similar to PAP and comparing CBT-I+PAP to PAP revealed superior performance in only attention/vigilance via psychomotor vigilance task lapses and verbal memory for PAP.

CONCLUSIONS

Treatment combinations involving CBT-I were associated with poorer neurocognitive performance. These potentially temporary effects may stem from sleep restriction, a component of CBT-I often accompanied by initially reduced total sleep time. Future studies should examine long-term effects of individual and combined COMISA treatment pathways to inform treatment recommendations.

CLINICAL TRIAL

This was an ancillary study from a clinical trial (Multidisciplinary Approach to the Treatment of Insomnia and Comorbid Sleep Apnea (MATRICS), which was preregistered at www.clinicaltrials.gov (NCT01785303)).