A randomized controlled trial of CBT-I and PAP for obstructive sleep apnea and comorbid insomnia: main outcomes from the MATRICS study

Multidisciplinary providers' perceptions of care delivery for sleep disorders: A qualitative case study

OBJECTIVES

Sleep disorders are wide-ranging in their causes and impacts on other physical and mental health conditions. Thus, sleep disorders could benefit from a multidisciplinary approach to assessment and treatment. An integrated care model is often recommended but is costly to implement. We sought to understand how, in the absence of an established organizational structure for integrated sleep care, providers from different clinics work together to provide care for sleep disorders.

METHODS

A qualitative case study at one U.S. Department of Veterans Affairs (VA) medical center. We used a purposeful nested sampling strategy, combining maximum variation sampling and snowball sampling to recruit key staff involved in sleep care.

RESULTS

We interviewed providers (N = 10) from sleep medicine, primary care, and mental health services. Providers identified the ubiquity of sleep disorders and a concomitant need for multidisciplinary care. However, they described limited opportunities for multidisciplinary interactions and consequently a negative impact on clinical care. Providers described fragmentation in two areas: among sleep specialists and between sleep specialists and other referring and managing providers.

CONCLUSIONS

A range of interventions, based on setting and resources, could improve care coordination both among sleep specialists and between sleep and nonsleep providers. While integrated sleep specialist clinics could reduce care fragmentation, they may not directly impact coordination with referring providers, like primary care and general mental health, who are essential in managing chronic conditions. Future work should continue to explore improving care coordination for sleep problems to ensure patients receive high-quality, timely, patient-centered care.

The effect of cognitive behavioural therapy for insomnia in people with comorbid insomnia and sleep apnoea: A systematic review and meta-analysis

Comorbid insomnia and sleep apnoea (COMISA) is a highly prevalent and debilitating sleep disorder. Cognitive behavioural therapy for insomnia (CBTi) may be an appropriate treatment for COMISA; however, no previous study has systematically reviewed and meta-analysed literature reporting on the effect of CBTi in people with COMISA. A systematic literature search was conducted across PsychINFO and PubMed (n = 295). In all, 27 full-text records were independently reviewed by at least two authors. Forward- and backward-chain referencing, and hand-searches were used to identify additional studies. Authors of potentially eligible studies were contacted to provide COMISA subgroup data. In total, 21 studies, including 14 independent samples of 1040 participants with COMISA were included. Downs and Black quality assessments were performed. A meta-analysis including nine primary studies measuring the Insomnia Severity Index indicated that CBTi is associated with a large improvement in insomnia severity (Hedges' g = -0.89, 95% confidence interval [CI] -1.35, -0.43). Subgroup meta-analyses indicated that CBTi is effective in samples with untreated obstructive sleep apnoea (OSA) (five studies, Hedges' g = -1.19, 95% CI -1.77, -0.61) and treated OSA (four studies, Hedges' g = -0.55, 95% CI -0.75, -0.35). Publication bias was evaluated by examining the Funnel plot (Egger's regression p = 0.78). Implementation programmes are required to embed COMISA management pathways in sleep clinics worldwide that currently specialise in the management of OSA alone. Future research should investigate and refine CBTi interventions in people with COMISA, including identifying the most effective CBTi components, adaptations, and developing personalised management approaches for this highly prevalent and debilitating condition.

Co-morbid insomnia and sleep apnea (COMISA): recent research and future directions

PURPOSE OF REVIEW

Insomnia and obstructive sleep apnea have previously been viewed as completely independent conditions. However, there is now increasing recognition that insomnia and sleep apnea frequently co-occur. Co-morbid insomnia and sleep apnea (COMISA) is a highly prevalent condition that is associated with impairment of sleep, daytime function, mental health and physical health outcomes, and mortality risk. This review aims to provide an update on COMISA prevalence, consequences, treatment approaches, and future research directions.

RECENT FINDINGS

People with COMISA experience worse sleep, mental health, physical health, quality of life and longevity compared to people with neither condition, and often compared to those with insomnia alone and sleep apnea alone. Emerging evidence suggests that cognitive behavioral therapy for insomnia is an effective treatment in the presence of treated and untreated sleep apnea, that may also improve manifestations and subsequent management of sleep apnea. Future research is required to understand the etiology of COMISA, and to develop and implement tailored treatment approaches.

SUMMARY

It is important for sleep and respiratory technicians, researchers and clinicians to be aware of the high co-morbidity rates, consequences, and treatment requirements of patients with co-morbid insomnia and sleep apnea.

The Impact of Sleep Disorders on Cardiovascular Health: Mechanisms and Interventions

This comprehensive review article explores the intricate mechanisms at work and possible remedies for the connection between sleep issues and cardiovascular health. Sleep disorders, which include conditions like insomnia and sleep apnea, are drawing increasing amounts of attention due to their serious detrimental consequences on cardiovascular health. This article carefully examines the body of existing evidence to explain the intricate mechanisms that connect sleep disruptions to cardiovascular issues. Mechanisms include inflammation, disruption of the autonomic nervous system, endothelial dysfunction, and aberrant metabolic processes all have an impact on these pathways. The study also looks at a variety of existing and novel therapeutic modalities that aim to minimize the detrimental effects of sleep disruptions on cardiovascular health. This includes evaluating the effectiveness of lifestyle changes, pharmaceutical interventions, and behavioural therapy for enhancing sleep quality and hence preserving cardiovascular health. By synthesising and presenting the most recent study data, this article offers valuable insights into the complex relationships between sleep patterns, cardiovascular function, and potential therapeutics. These results provide a solid foundation for guiding future research endeavours and clinical judgements. Pharmacotherapy is a possibility for momentary relief. Cardiovascular illness has been linked to the sensorimotor problem known as restless legs syndrome (RLS), which causes a strong impulse to move the legs. Sleep disruption caused by RLS-related leg movements leads to sympathetic activation, elevated blood pressure, impaired vascular function, and potential iron deficiency. Treating the underlying iron deficiency, when present, and medications targeting dopamine receptors or regulating calcium channels are the primary interventions for RLS. In conclusion, sleep disorders significantly impact cardiovascular health through multiple mechanisms. Early detection, accurate diagnosis, and appropriate interventions are crucial for mitigating associated cardiovascular risks. Multidisciplinary approaches including lifestyle modifications, behavioral interventions, and targeted pharmacotherapy have shown promise in improving sleep quality and cardiovascular outcomes. Further research is needed to enhance our understanding of the complex interplay between sleep disorders and cardiovascular health, leading to the development of more effective interventions and improved patient outcomes.

Relationship between Symptom Profiles and Endotypes among Patients with Obstructive Sleep Apnea: A Latent Class Analysis

Rationale: Obstructive sleep apnea (OSA) is a heterogeneous syndrome with various endotypic traits and symptoms. A link among symptoms, endotypes, and disease prognosis has been proposed but remains unsupported by empirical data. Objectives: To link symptom profiles and endotypes by clustering endotypic traits estimated using polysomnographic signals. Methods: We recruited 509 patients with moderate to severe OSA from a single sleep center. Polysomnographic data were collected between May 2020 and January 2022. Endotypic traits, namely arousal threshold, upper airway collapsibility, loop gain, and upper airway muscle compensation, were retrieved using polysomnographic signals during non-rapid eye movement periods. We used latent class analysis to group participants into endotype clusters. Demographic and polysomnographic parameter differences were compared between clusters, and associations between endotype clusters and symptom profiles were examined using logistic regression analyses. Results: Three endotype clusters were identified, characterized by high collapsibility/loop gain, low arousal threshold, and low compensation, respectively. Patients in each cluster exhibited similar demographic characteristics, but those in the high collapsibility/loop gain cluster had the highest proportion of obesity and severe oxygen desaturation observed in polysomnographic studies. The low compensation cluster was characterized by fewer sleepy symptoms and exhibited a lower rate of diabetes mellitus. Compared with the excessively sleepy group, disturbed sleep symptoms were associated with the low arousal threshold cluster (odds ratio, 1.89; 95% confidence interval, 1.16-3.10). Excessively sleepy symptoms were associated with the high collapsibility/loop gain cluster (odds ratio, 2.16; 95% confidence interval, 1.39-3.37) compared with the minimally symptomatic group. Conclusions: Three pathological endotype clusters were identified among patients with moderate to severe OSA, each exhibiting distinct polysomnographic characteristics and clinical symptom profiles.

Cognitive Behavioral Therapy for Insomnia Among Active Duty Military Personnel Diagnosed With Obstructive Sleep Apnea

INTRODUCTION

Insomnia and obstructive sleep apnea are common conditions among military service members, with high rates of comorbidity. Although cognitive behavioral therapy for insomnia (CBT-I) has been established as an effective treatment for insomnia, it is unclear whether or not CBT-I is effective among service members with comorbid insomnia and obstructive sleep apnea.

MATERIALS AND METHODS

This retrospective, observational study examined insomnia outcomes among a group of service member patients (N = 73) with comorbid insomnia and obstructive sleep apnea. All patients received individual CBT-I in a specialty sleep clinic at a military treatment facility. Seven outcomes associated with insomnia were evaluated before and after treatment.

RESULTS

On average, patients showed significant improvement in sleep onset latency, wake after sleep onset, sleep efficiency, number of awakenings, and symptoms reported on the Insomnia Severity Index. Twenty-six percent of patients showed clinically significant improvement in reported insomnia symptoms.

CONCLUSIONS

These results suggest that CBT-I may be effective in treating military service members with comorbid insomnia and obstructive sleep apnea. Despite the limitations of data collected in a clinical setting, consistent findings across five of the seven outcome measures provide good evidence that this treatment can be implemented in military settings.

Translation of obstructive sleep apnea pathophysiology and phenotypes to personalized treatment: a narrative review

Obstructive Sleep Apnea (OSA) arises due to periodic blockage of the upper airway (UA) during sleep, as negative pressure generated during inspiration overcomes the force exerted by the UA dilator muscles to maintain patency. This imbalance is primarily seen in individuals with a narrowed UA, attributable to factors such as inherent craniofacial anatomy, neck fat accumulation, and rostral fluid shifts in the supine posture. Sleep-induced attenuation of UA dilating muscle responsiveness, respiratory instability, and high loop gain further exacerbate UA obstruction. The widespread comorbidity profile of OSA, encompassing cardiovascular, metabolic, and neuropsychiatric domains, suggests complex bidirectional relationships with conditions like heart failure, stroke, and metabolic syndrome. Recent advances have delineated distinct OSA phenotypes beyond mere obstruction frequency, showing links with specific symptomatic manifestations. It is vital to bridge the gap between measurable patient characteristics, phenotypes, and underlying pathophysiological traits to enhance our understanding of OSA and its interplay with related outcomes. This knowledge could stimulate the development of tailored therapies targeting specific phenotypic and pathophysiological endotypes. This review aims to elucidate the multifaceted pathophysiology of OSA, focusing on the relationships between UA anatomy, functional traits, clinical manifestations, and comorbidities. The ultimate objective is to pave the way for a more personalized treatment paradigm in OSA, offering alternatives to continuous positive airway pressure therapy for selected patients and thereby optimizing treatment efficacy and adherence. There is an urgent need for personalized treatment strategies in the ever-evolving field of sleep medicine, as we progress from a 'one-size-fits-all' to a 'tailored-therapy' approach.

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)).

International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

METHODS

Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.

RESULTS

The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.

CONCLUSION

This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

The beneficial effects of integrating a personalized telephone-delivered component into digital cognitive behavioral therapy for insomnia in a large, hospital-based population

OBJECTIVES

Although digital cognitive behavior therapy for insomnia (D-CBTI) has been shown to be a viable treatment for insomnia, lacking flexibility of response and direct practitioner-to-patient contact and comfort potentially limited its efficacy. Integrating personalized telephone sessions into D-CBTI may overcome these obstacles, potentially providing additional clinical benefit to chronic insomnia patients. We evaluate the clinical effectiveness of telephone plus D-CBTI (TD-CBTI) versus D-CBTI alone.

METHODS

Insomnia patients were selected consecutively from the Sleep Medicine Center, West China Hospital from March 2020 to February 2021. Insomnia was defined by Diagnostic and Statistical Manual for Mental Disorders criteria with symptoms lasting ≥3 months. Standard D-CBTI was administered through the APP "SUMIAN," which provided fully automated, interactive and standard CBTI over six weekly treatments. TD-CBTI added weekly 10-15 min personalized telephone-based sessions to D-CBTI.

RESULTS

One hundred and seven patients received D-CBTI and 465 patients received TD-CBTI. Pre-to posttreatment differences of ISI and most sleep diary reported sleep indexes were comparable between groups. However, TD-CBTI patients showed significantly increased odds of SE based remission (167%, OR = 2.67, 95% CI 1.34-5.23), and significantly increased odds of reduction of sleep medications (352%, OR = 4.52, 95% CI 1.27-10.05).

CONCLUSIONS

This study demonstrates that integration of personalized telephone sessions into D-CBTI treatment, provides increased clinical benefit to insomnia patients, particularly for successful discontinuation of sleep medications.

Moving toward Equitable Care for Sleep Apnea in the United States: Positive Airway Pressure Adherence Thresholds: An Official American Thoracic Society Policy Statement

Background: Positive airway pressure (PAP) is a highly effective treatment for obstructive sleep apnea (OSA), but adherence limits its efficacy. In addition, coverage of PAP by CMS (Centers for Medicare & Medicaid Services) and other insurers in the United States depends on adherence. This leaves many beneficiaries without PAP, disproportionally impacting non-white and low socioeconomic position patients with OSA and exacerbating sleep health disparities. Methods: An inter-professional, multidisciplinary, international committee with various stakeholders was formed. Three working groups (the historical policy origins, impact of current policy, and international PAP coverage models) met and performed literature reviews and discussions. Using surveys and an iterative discussion-based consensus process, the policy statement recommendations were created. Results: In this position paper, we advocate for policy change to CMS PAP coverage requirements to reduce inequities and align with patient-centered goals. We specifically call for eradicating repeat polysomnography, eliminating the 4-hour rule, and focusing on patient-oriented outcomes such as improved sleepiness and sleep quality. Conclusions: Modifications to the current policies for PAP insurance coverage could improve health disparities.

Pharmacopuncture Effects on Insomnia Disorder: Protocol for a Multi-Site, Randomized, Acupuncture-Controlled, Clinical Trial

Insomnia is a common health problem that can lead to various diseases and negatively impact quality of life. Pharmacopuncture is a new type of acupuncture that involves applying herbal medicine extracts to acupoints. Korean medicine doctors frequently use it to treat insomnia disorder. However, there is insufficient evidence to support the effectiveness and safety of pharmacopuncture for insomnia disorder. We designed a pragmatic randomized controlled trial to compare the effectiveness of pharmacopuncture and acupuncture for insomnia disorder. This multi-site, randomized, acupuncture-controlled trial will enroll 138 insomnia patients. The subjects will be randomly assigned to one of two groups, pharmacopuncture or acupuncture, at a 2:1 ratio. For 4 weeks, the participants will receive ten sessions of pharmacopuncture or acupuncture treatment and will be followed up for 4 weeks after the treatment ends. The Pittsburgh Sleep Quality Index score is the primary outcome measure. Insomnia severity index score, sleep parameters recorded using actigraphy and sleep diaries, physical symptoms associated with insomnia, emotions, quality of life, medical costs, and safety are the secondary outcome measures. The findings of this trial willprovide evidence that will be useful in clinical decision-making for insomnia treatment strategies.

Stepped care management of insomnia co-occurring with sleep apnea: the AIR study protocol

Background

Obstructive sleep apnea (OSA) and insomnia are commonly co-occurring conditions that amplify morbidity and complicates the management of affected patients. Unfortunately, previous research provides limited guidance as to what constitutes the best and most practical management approach for this comorbid patient group. Some preliminary studies show that when cognitive behavioral insomnia therapy (CBT-I) is combined with standard OSA therapies for these patients, outcomes are improved. However, the dearth of trained providers capable of delivering CBT-I has long served as a pragmatic barrier to the widespread use of this therapy in clinical practice. The emergence of sophisticated online CBT-I (OCBT-I) programs could improve access, showing promising reductions in insomnia severity. Given its putative scalability and apparent efficacy, some have argued OCBT-I should represent a 1st-stage intervention in a broader stepped care model that allocates more intensive and less assessable therapist-delivered CBT-I (TCBT-I) only to those who show an inadequate response to lower intensity OCBT-I. However, the efficacy of OCBT-I as a 1st-stage therapy within a broader stepped care management strategy for insomnia comorbid with OSA has yet to be tested with comorbid OSA/insomnia patients.

Methods/design

This dual-site randomized clinical trial will use a Sequential Multiple Assignment Randomized Trial (SMART) design to test a stepped care model relative to standard positive airway pressure (PAP) therapy and determine if (1) augmentation of PAP therapy with OCBT-I improves short-term outcomes of comorbid OSA/insomnia and (2) providing a higher intensity 2nd-stage CBT-I to patients who show sub-optimal short-term outcomes with OCBT-I+PAP improves short and longer-term outcomes. After completing baseline assessment, the comorbid OSA/insomnia patients enrolled will be randomized to a 1st-stage therapy that includes usual care PAP + OCBT-I or UC (usual care PAP + sleep hygiene education). Insomnia will be reassessed after 8 weeks. OCBT-I recipients who meet “remission” criteria (defined as an Insomnia Severity Index score < 10) will continue PAP but will not be offered any additional insomnia intervention and will complete study outcome measures again after an additional 8 weeks and at 3 and 6 month follow-ups. OCBT-I recipients classified as “unremitted” after 8 weeks of treatment will be re-randomized to a 2nd-stage treatment consisting of continued, extended access to OCBT-I or a switch to TCBT-I. Those receiving the 2nd-stage intervention as well as the UC group will be reassessed after another 8 weeks and at 3- and 6-month follow-up time points. The primary outcome will be insomnia remission. Secondary outcomes will include subjective and objective sleep data, including sleep time, sleep efficiency, fatigue ratings, PAP adherence, sleepiness ratings, sleep/wake functioning ratings, and objective daytime alertness.

Discussion

This study will provide new information about optimal interventions for patients with comorbid OSA and insomnia to inform future clinical decision-making processes.

Trial registration

ClinicalTrials.gov, NCT03109210, registered on April 12, 2017, prospectively registered.

Effects of schedule exercise therapy on chronic insomnia

Schedule exercise therapy (SET) is a novel nonpharmacological intervention for the treatment of chronic insomnia disorder (CID). The aim of this study was to explore the effects of SET on CID. Methods: One hundred and eighteen CID were recruited and randomized into medication (MED) or medication combined with SET (MSET) groups. Over 12 observational weeks, sleep and mood status were evaluated using the Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), Epworth Sleepiness Scale (ESS), Self-rating Depression Scale (SDS), and Self-rating Anxiety Scale (SAS). At the end of the observational period, the rates of clinically effective hypnotic use were calculated. At 12 weeks, the PSQI progressively decreased for all subjects combined (P < .001) as well as ISI (P < .001), ESS (P < .001), SDS (P < .001), and SAS (P < .001). The decreases in PSQI (P < .05), ISI (P < .05), SDS (P < .01), and SAS (P < .05) in the MSET group were significantly larger than those in the MED group, but not the same as those in the ESS group (P > .05). At the trial endpoint, the clinically effective rate was significantly higher (P < .05) and the hypnotic usage rate was lower (P < .05) in the MSET group than in the MED group. SET may be an effective treatment for insomnia in patients with CID.

Sleep Deficiency in Obstructive Sleep Apnea

Sleep deficiency in patients with obstructive sleep apnea includes abnormal quality, timing, and duration of sleep, and the presence of other comorbid conditions. These include insomnia, circadian misalignment disorders, and periodic limb movements of sleep. The co-occurrence of these conditions with obstructive sleep apnea likely plays a role in the pathogenesis, clinical presentation, and management of obstructive sleep apnea. Considering these conditions and their treatment in evaluating sleep deficiency in obstructive sleep apnea may help to improve patient outcomes. However, future research is needed to understand the intersection between obstructive sleep apnea and these disorders.

Treating sleep and circadian problems to promote mental health: perspectives on comorbidity, implementation science and behavior change

Insufficient sleep and mistimed sleep are prominent, yet under-appreciated and understudied, contributors to poor mental health and to mental disorders. The evidence that improving sleep and circadian functioning is an important pathway to mental health continues to mount. The goal of this paper is to highlight three major challenges ahead. Challenge 1 points to the possibility that comorbidity is the norm not the exception for the sleep and circadian disorders that are associated with mental disorders. Hence, the sleep and circadian problems experienced by people diagnosed with a mental disorder may not fit into the neat diagnostic categories of existing nosologies nor be adequately treated with single disorder approaches. The Sleep Health Framework and the Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C) are discussed as alternative approaches. Challenge 2 points to the large time lag between the development of a treatment and the availability of that treatment in routine clinical practice. This is a key reason for the emergence of implementation science, which is a flourishing, well-developed, and quickly moving field. There is an urgent need for more applications of implementation science within sleep and circadian science. Challenge 3 describes one of the greatest puzzles of our time-the need to unlock the fundamental elements of behavior change. There is potential to harness the science of behavior change to encourage widespread engagement in sleep health behavior and thereby reduce the staggering burden of sleep and circadian problems and the associated mental health problems.

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

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://clinicaltrials.gov/ct2/show/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.

Sleep-Disordered Breathing Risk with Comorbid Insomnia Is Associated with Mild Cognitive Impairment

Introduction: Few studies have evaluated the combined association between SDB with comorbid insomnia and mild cognitive impairment (MCI). To test the hypothesis that SDB with comorbid insomnia is associated with greater odds of MCI than either sleep disorder independently, we used ADNI data to evaluate cross-sectional associations between SDB risk with comorbid insomnia status and MCI. Methods: Participants with normal cognition or MCI were included. Insomnia was defined by self-report. SDB risk was assessed by modified STOP-BANG. Logistic regression models evaluated associations between four sleep disorder subgroups (low risk for SDB alone, low risk for SDB with insomnia, high risk for SDB alone, and high risk for SDB with insomnia) and MCI. Models adjusted for age, sex, BMI, APOE4 genotype, race, ethnicity, education, marital status, hypertension, cardiovascular disease, stroke, alcohol abuse, and smoking. Results: The sample (n = 1391) had a mean age of 73.5 ± 7.0 years, 44.9% were female, 72.0% were at low risk for SDB alone, 13.8% at low risk for SDB with insomnia, 10.1% at high risk for SDB alone, and 4.1% at high risk for SDB with insomnia. Only high risk for SDB with comorbid insomnia was associated with higher odds of MCI (OR 3.22, 95% CI 1.57–6.60). Conclusion: Studies are needed to evaluate SDB with comorbid insomnia as a modifiable risk factor for MCI.

The Effect of Cognitive Behavioural Therapy for Insomnia (CBT-I) on Subjective–Objective Sleep Discrepancy in Individuals with Co-Morbid Insomnia and Sleep Apnoea: A Randomised Controlled Trial

People with insomnia frequently underestimate the duration of their sleep compared to objective polysomnography-measured sleep duration. Cognitive behavioural therapy for insomnia (CBT-I) is the most effective treatment for insomnia and also reduces the degree of sleep underestimation. Obstructive sleep apnoea (OSA) is a highly prevalent sleep disorder characterised by frequent narrowing (hypopnoea) and closure (apnoea) of the upper airway during sleep. Comorbid insomnia and sleep apnoea (COMISA) is a prevalent and debilitating disorder. No study has investigated subjectively (sleep diary) versus objectively (polysomnography) measured sleep discrepancies (SOSD) in individuals with COMISA before or following CBT-I. This randomised waitlist-controlled trial investigated SOSD in 145 participants with COMISA before and 6-weeks after CBT-I (n = 72) versus control (n = 73). All participants were studied prior to continuous positive airway pressure treatment for sleep apnoea. At baseline, participants underestimated their total sleep time (mean ± SD −51.9 ± 94.1 min) and sleep efficiency (−9.6 ± 18.3%), and overestimated sleep onset latency (34.5 ± 86.1 min; all p = < 0.001). Mixed models indicated a main effect of time on reduction of SOSD in both groups, but no between-group difference in the reduction of any SOSD parameters. These findings may indicate that untreated OSA contributes to a discrepancy between perceived and objective sleep parameters in people with COMISA that is not amenable to CBT-I alone (ACTRN12613001178730).

Cognitive Behavioral Therapy for Insomnia has sustained effects on insomnia, fatigue, and function among people with chronic heart failure and insomnia: The HeartSleep Study

STUDY OBJECTIVES

Insomnia is common among adults with chronic heart failure (HF) and associated with daytime symptoms and decrements in function. The purpose of this randomized controlled trial (RCT) was to evaluate the sustained effects over one year of CBT-I (Healthy Sleep: HS) compared with HF self-management education (Healthy Hearts; attention control: HH) on insomnia severity, sleep characteristics, symptoms, and function among people with stable HF. The primary outcomes were insomnia severity, actigraph-recorded sleep efficiency, and fatigue.

METHODS

We randomized adults with stable HF with preserved or reduced ejection fraction who had at least mild insomnia (Insomnia severity index >7) in groups to HS or HH (4 sessions/8 weeks). We obtained wrist actigraphy and measured insomnia severity, self-reported sleep characteristics, symptoms (fatigue, excessive daytime sleepiness, anxiety, depression), and six-minute walk distance at baseline, within one month of treatment, and at 6 and 12 months. We used general linear mixed models (GLMM) and generalized estimating equations (GEE) to evaluate the effects.

RESULTS

The sample included 175 participants (M age = 63 +12.9 years; 43% women; 18% Black; 68% New York Heart Association Class II or II; 33%; LVEF < 45%) randomized to HS (n = 91) or HH (N = 84). HS had sustained effects on insomnia severity, sleep quality, self-reported sleep latency and efficiency, fatigue, excessive daytime sleepiness, and six-minute walk distance at 12 months.

CONCLUSIONS

CBT-I produced sustained improvements in insomnia, fatigue, daytime sleepiness, and objectively measured physical function among adults with chronic HF, compared with a robust HF self-management program that included sleep hygiene education.

Effect of Continuous Positive Airway Pressure on Symptoms and Prevalence of Insomnia in Patients With Obstructive Sleep Apnea: A Longitudinal Study

Objective

Obstructive sleep apnea (OSA) and insomnia are the two most common sleep disorders. Continuous positive airway pressure (CPAP) is considered first-line treatment for OSA. In the present study, we assess the effect of CPAP on symptoms and prevalence of insomnia in patients with OSA. We hypothesized a decrease in insomnia symptoms from CPAP initiation to follow-up, and that this decrease would depend on CPAP adherence.

Materials and methods

The sample included 442 patients diagnosed with OSA [mean age 54.9 years (SD = 12.1), 74.4% males] who started treatment with CPAP at a university hospital. OSA was diagnosed according to standard respiratory polygraphy. Mean apnea-hypopnea index (AHI) was 30.1 (SD = 21.1) at baseline. Insomnia was assessed prior to CPAP treatment (baseline) and at follow-up after a median of 19.9 weeks (range 6–52 weeks) with the Bergen Insomnia Scale (BIS). CPAP adherence was defined as an average use of ≥ 4 h per night, whereas non-adherence was defined as < 4 h per night.

Results

There was a significant decrease in BIS scores from baseline (mean = 18.8, SD = 9.8) to follow-up (mean = 12.9, SD = 9.9), p < 0.001. Cohen’s d(0.65) indicated a moderate effect size. The reduction in BIS scores was depending on CPAP adherence (interaction effect F(1,440) = 12.4, p < 0.001), with larger reduction in the adherent group than in the non-adherent group. The proportion of patients with chronic insomnia was significantly reduced from 51.1% at baseline to 33.0% at follow-up (p < 0.001).

Conclusion

Overall, there was a significant reduction in insomnia symptoms from baseline to follow-up. The improvement was significant in both adherence groups, but the degree of improvement was larger among patients who were adherent to CPAP. Furthermore, there was a significant reduction in the prevalence of chronic insomnia at follow-up compared to baseline. This suggests that CPAP effectively reduces both the presence of insomnia and the severity of insomnia symptoms in some patients with OSA.

Effect of depression, anxiety, and stress symptoms on response to cognitive behavioral therapy for insomnia in patients with comorbid insomnia and sleep apnea: a randomized controlled trial

STUDY OBJECTIVES

Patients with comorbid insomnia and sleep apnea (COMISA) report increased severity of depression, anxiety, and stress symptoms compared to patients with either insomnia or sleep apnea alone. Although cognitive behavioral therapy for insomnia (CBTi) is an effective treatment for COMISA, previous research suggests a reduced response to CBTi by patients with insomnia and depression, anxiety, and stress symptoms. Therefore, we used randomized controlled trial data to investigate the impact of depression, anxiety, and stress symptoms before treatment on changes in insomnia after CBTi vs control in patients with COMISA.

METHODS

145 patients with COMISA (insomnia as defined by the International Classification of Sleep Disorders, third edition and apnea-hypopnea index ≥ 15 events/h) were randomized to CBTi (n = 72) or no-treatment control (n = 73). One-week sleep diaries and standardized questionnaire measures of insomnia, sleepiness, fatigue, depression, anxiety, and stress were completed pretreatment and posttreatment. Mixed models were used to examine interactions between depression, anxiety, and stress symptoms before treatment, intervention-group (CBTi, control), and time (pretreatment, posttreatment) on insomnia symptoms.

RESULTS

Approximately half of this COMISA sample reported at least mild symptoms of depression (57%), anxiety (53%), and stress (48%) before treatment. Patients reporting greater depression, anxiety, and stress symptoms before treatment also reported increased severity of insomnia, daytime fatigue, and sleepiness. Improvements in questionnaire and diary-measured insomnia symptoms improved during CBTi and were not moderated by severity of depression, anxiety, or stress symptoms before treatment (all interaction P ≥ .11).

CONCLUSIONS

We found no evidence that symptoms of depression, anxiety, or stress impair the effectiveness of CBTi in improving insomnia symptoms in patients with COMISA. Patients with COMISA and comorbid symptoms of depression, anxiety, and stress should be referred for CBTi to treat insomnia and improve subsequent management of their obstructive sleep apnea.

CLINICAL TRIAL REGISTRATION

Registry: Australian New Zealand Clinical Trials Registry; Name: Treating comorbid insomnia with obstructive sleep apnea (COMISA) study: A new treatment strategy for patients with combined insomnia and sleep apnea; URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=365184; Identifier: ACTRN12613001178730.

Bi-directional relationships between co-morbid insomnia and sleep apnea (COMISA)

Insomnia and obstructive sleep apnea (OSA) commonly co-occur. Approximately 30-50% of patients with OSA report clinically significant insomnia symptoms, and 30-40% of patients with chronic insomnia fulfil diagnostic criteria for OSA. Compared to either insomnia or OSA alone, co-morbid insomnia and sleep apnea (COMISA) is associated with greater morbidity for patients, complex diagnostic decisions for clinicians, and reduced response to otherwise effective treatment approaches. Potential bi-directional causal relationships between the mechanisms and manifestations of insomnia and OSA could play an integral role in the development and management of COMISA. A greater understanding of these relationships is required to guide personalized diagnostic and treatment approaches for COMISA. This review summarizes the available evidence of bi-directional relationships between COMISA, including epidemiological research, case studies, single-arm treatment studies, randomized controlled treatment trials, and objective sleep study data. This evidence is integrated into a conceptual model of COMISA to help refine the understanding of potential bi-directional causal relationships between the two disorders. This theoretical framework is essential to help guide future research, improve diagnostic tools, determine novel therapeutic targets, and guide tailored sequenced and multi-faceted treatment approaches for this common, complex, and debilitating condition.

Polysomnographic Predictors of Treatment Response to Cognitive Behavioral Therapy for Insomnia in Participants With Co-morbid Insomnia and Sleep Apnea: Secondary Analysis of a Randomized Controlled Trial

OBJECTIVE

Co-morbid insomnia and sleep apnea (COMISA) is a common and debilitating condition that is more difficult to treat compared to insomnia or sleep apnea-alone. Emerging evidence suggests that cognitive behavioral therapy for insomnia (CBTi) is effective in patients with COMISA, however, those with more severe sleep apnea and evidence of greater objective sleep disturbance may be less responsive to CBTi. Polysomnographic sleep study data has been used to predict treatment response to CBTi in patients with insomnia-alone, but not in patients with COMISA. We used randomized controlled trial data to investigate polysomnographic predictors of insomnia improvement following CBTi, versus control in participants with COMISA.

METHODS

One hundred and forty five participants with insomnia (ICSD-3) and sleep apnea [apnea-hypopnea index (AHI) ≥ 15] were randomized to CBTi (n = 72) or no-treatment control (n = 73). Mixed models were used to investigate the effect of pre-treatment AHI, sleep duration, and other traditional (AASM sleep macrostructure), and novel [quantitative electroencephalography (qEEG)] polysomnographic predictors of between-group changes in Insomnia Severity Index (ISI) scores from pre-treatment to post-treatment.

RESULTS

Compared to control, CBTi was associated with greater ISI improvement among participants with; higher AHI (interaction p = 0.011), less wake after sleep onset (interaction p = 0.045), and less N3 sleep (interaction p = 0.005). No quantitative electroencephalographic, or other traditional polysomnographic variables predicted between-group ISI change (all p > 0.09).

DISCUSSION

Among participants with COMISA, higher OSA severity predicted a greater treatment-response to CBTi, versus control. People with COMISA should be treated with CBTi, which is effective even in the presence of severe OSA and objective sleep disturbance.

Sleep Apnea and Insomnia: Emerging Evidence for Effective Clinical Management

Comorbid insomnia and sleep apnea (COMISA) are the most common co-occurring sleep disorders and present many challenges to clinicians. This review provides an overview of the clinical challenges in the management of patients with COMISA, with a focus on recent evidence regarding the evaluation and treatment of COMISA. Innovations in the assessment of COMISA have used profile analyses or dimensional approaches to examine symptom clusters or symptom severity that could be particularly useful in the assessment of COMISA. Recent randomized controlled trials have provided important evidence about the safety and effectiveness of a concomitant treatment approach to COMISA using cognitive-behavioral therapy for insomnia (CBT-I) with positive airway pressure (PAP). Furthermore, patient-centered considerations that integrate patient characteristics, treatment preferences, and accessibility to treatment in the context of COMISA are discussed as opportunities to improve patient care. Based on these recent advances and clinical perspectives, a model for using multidisciplinary, patient-centered care is recommended to optimize the clinical management of patients with COMISA.

Randomized controlled trial of an integrated approach to treating insomnia and improving the use of positive airway pressure therapy in veterans with comorbid insomnia disorder and obstructive sleep apnea

STUDY OBJECTIVES

Cognitive behavioral therapy for insomnia (CBTI) for comorbid insomnia and obstructive sleep apnea (OSA) has had mixed results. We integrated CBTI with a positive airway pressure (PAP) adherence program and tested effects on sleep and PAP use.

METHODS

125 veterans (mean age 63.2, 96% men, 39% non-Hispanic white, 26% black/African American, 18% Hispanic/Latino) with comorbid insomnia and newly-diagnosed OSA (apnea-hypopnea index ≥ 15) were randomized to 5-weekly sessions integrating CBTI with a PAP adherence program provided by a "sleep coach" (with behavioral sleep medicine supervision), or 5-weekly sleep education control sessions. Participants and assessment staff were blinded to group assignment. Outcomes (baseline, 3 and 6 months) included Pittsburgh Sleep Quality Index (PSQI), 7-day sleep diary (sleep onset latency [SOL-D], wake after sleep onset [WASO-D], sleep efficiency [SE-D]), 7-day actigraphy (SE-A), and objective PAP use (hours/night and nights ≥ 4 h). Insomnia Severity Index (ISI), Epworth Sleepiness Scale (ESS), and Functional Outcomes of Sleep Questionnaire-10 (FOSQ-10) were also collected.

RESULTS

Compared to controls, intervention participants showed greater improvement (baseline to 3 and 6 months, respectively) in PSQI (-3.2 and -1.7), SOL-D (-16.2 and -15.5 minutes), SE-D (10.5% and 8.5%), SE-A (4.4% and 2.6%) and more 90-day PAP use (1.3 and 0.9 more hours/night, 17.4 and 11.3 more nights PAP ≥ 4 h). 90-day PAP use at 3 months was 3.2 and 1.9 h/night in intervention versus controls. Intervention participants also had greater improvements in ISI, ESS, and FOSQ-10 (all p < 0.05).

CONCLUSIONS

An intervention integrating CBTI with a PAP adherence program delivered by a supervised sleep coach improved sleep and PAP use in adults with comorbid insomnia and OSA.

TRIAL REGISTRATION

ClinicalTrials.govStudy name: Novel Treatment of Comorbid Insomnia and Sleep Apnea in Older VeteransURL: https://clinicaltrials.gov/ct2/results?cond=&term=NCT02027558&cntry=&state=&city=&dist=Registration: NCT02027558.

Insomnia - A Heterogenic Disorder Often Comorbid With Psychological and Somatic Disorders and Diseases: A Narrative Review With Focus on Diagnostic and Treatment Challenges

Patients with insomnia complain of problems with sleep onset or sleep maintenance or early morning awakenings, or a combination of these, despite adequate opportunity and circumstances for sleep. In addition, to fulfill the diagnostic criteria for insomnia the complaints need to be associated with negative daytime consequences. For chronic insomnia, the symptoms are required to be present at least 3 days per week for a duration of at least 3 months. Lastly, for insomnia to be defined as a disorder, the sleep complaints and daytime symptoms should not be better explained by another sleep disorder. This criterion represents a diagnostic challenge, since patients suffering from other sleep disorders often complain of insomnia symptoms. For instance, insomnia symptoms are common in e.g., obstructive sleep apnea and circadian rhythm sleep-wake disorders. It may sometimes be difficult to disentangle whether the patient suffers from insomnia disorder or whether the insomnia symptoms are purely due to another sleep disorder. Furthermore, insomnia disorder may be comorbid with other sleep disorders in some patients, e.g., comorbid insomnia and sleep apnea (COMISA). In addition, insomnia disorder is often comorbid with psychological or somatic disorders and diseases. Thus, a thorough assessment is necessary for correct diagnostics. For chronic insomnia disorder, treatment-of-choice is cognitive behavioral therapy, and such treatment is also effective when the insomnia disorder appears comorbid with other diagnoses. Furthermore, studies suggest that insomnia is a heterogenic disorder with many different phenotypes or subtypes. Different insomnia subtypes may respond differently to treatment, but more research on this issue is warranted. Also, the role of comorbidity on treatment outcome is understudied. This review is part of a Research Topic on insomnia launched by Frontiers and focuses on diagnostic and treatment challenges of the disorder. The review aims to stimulate to more research into the bidirectional associations and interactions between insomnia disorder and other sleep, psychological, and somatic disorders/diseases.

Total Sleep Deprivation Followed by Bright Light Therapy as Rapid Relief for Depression: A Pragmatic Randomized Controlled Trial

Background: Total sleep deprivation (TSD) combined with bright light therapy (BLT) has been suggested as a valuable add-on to standard treatment for rapid relief of depression. However, there is a lack of randomized controlled trials in real-life clinical settings. The aim of this pragmatic randomized clinical trial was to investigate the effectiveness, acceptance, and feasibility of TSD combined with BLT as add-on to standard treatment for depression in a real-life clinical setting. Methods: Thirty-three inpatients were randomly assigned to either: a) an intervention group receiving a single-night TSD followed by 6 days BLT (10.000 lux, 30 min/day) as add-on to standard treatment; or b) a control group receiving a short sleep-hygiene consultation in addition to standard treatment. The follow-up period was 1 week. Results: No statistical differences were found in response rates, reduction of depressive and insomnia symptoms, length of stay, readmission rate, and clinical improvement. Both groups reported positive experiences toward the received treatment with low drop-out rates. Conclusions: One-night TSD followed by BLT was not effective as a rapid relief for depression at 1-week follow-up; however, the treatment was feasible and well-tolerated.