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Cognitive behavioral therapy for insomnia (CBT-I) in the treatment of comorbid insomnia and sleep apnea (COMISA)

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2.6.2026
Markku Partinen

Cognitive behavioral therapy for insomnia (CBT-I) is effective for the treatment of comorbid insomnia and sleep apnea (COMISA), producing large improvements in insomnia severity, sleep efficiency, and sleep quality, regardless of whether obstructive sleep apnea (OSA) is treated or untreated «Sweetman A, Farrell S, Wallace DM, ym. The effect of cognitive behavioural therapy for insomnia in people with comorbid insomnia and sleep apnoea: A systematic review and meta-analysis. J Sleep Res 20»1, «Sweetman A, Richardson C, Smith A, ym. The Effect of Digital Cognitive Behavioural Therapy for Insomnia in People With Co-Morbid Insomnia and Sleep Apnoea (COMISA): A Pilot Randomised Controlled Trial»2, «Sweetman A, Lechat B, Catcheside PG, ym. Polysomnographic Predictors of Treatment Response to Cognitive Behavioral Therapy for Insomnia in Participants With Co-morbid Insomnia and Sleep Apnea: Seconda»3, «Ong JC, Crawford MR, Wallace DM. Sleep Apnea and Insomnia: Emerging Evidence for Effective Clinical Management. Chest 2021;159(5):2020-2028 »4, «Sweetman A, McEvoy RD, Smith S, ym. The effect of cognitive and behavioral therapy for insomnia on week-to-week changes in sleepiness and sleep parameters in patients with comorbid insomnia and sleep »5, «Sharafkhaneh A, Thomas A, Ulmer C, ym. The Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea (Insomnia/OSA). Department of Veterans Affairs. 20253»6, «Ragnoli B, Pochetti P, Raie A, ym. Comorbid Insomnia and Obstructive Sleep Apnea (COMISA): Current Concepts of Patient Management. Int J Environ Res Public Health 2021;18(17): »7, «Ong JC, Crawford MR, Dawson SC, ym. A randomized controlled trial of CBT-I and PAP for obstructive sleep apnea and comorbid insomnia: main outcomes from the MATRICS study. Sleep 2020;43(9): »8, «Tu AY, Crawford MR, Dawson SC, ym. A randomized controlled trial of cognitive behavioral therapy for insomnia and PAP for obstructive sleep apnea and comorbid insomnia: effects on nocturnal sleep and »9.

Meta-analyses and randomized controlled trials demonstrate that CBT-I leads to significant reductions in Insomnia Severity Index scores and improvements in sleep parameters in COMISA populations, with effect sizes comparable to those seen in insomnia alone «Sweetman A, Farrell S, Wallace DM, ym. The effect of cognitive behavioural therapy for insomnia in people with comorbid insomnia and sleep apnoea: A systematic review and meta-analysis. J Sleep Res 20»1, «Sweetman A, Richardson C, Smith A, ym. The Effect of Digital Cognitive Behavioural Therapy for Insomnia in People With Co-Morbid Insomnia and Sleep Apnoea (COMISA): A Pilot Randomised Controlled Trial»2, «Sweetman A, Lechat B, Catcheside PG, ym. Polysomnographic Predictors of Treatment Response to Cognitive Behavioral Therapy for Insomnia in Participants With Co-morbid Insomnia and Sleep Apnea: Seconda»3, «Sweetman A, McEvoy RD, Smith S, ym. The effect of cognitive and behavioral therapy for insomnia on week-to-week changes in sleepiness and sleep parameters in patients with comorbid insomnia and sleep »5, «Ong JC, Crawford MR, Dawson SC, ym. A randomized controlled trial of CBT-I and PAP for obstructive sleep apnea and comorbid insomnia: main outcomes from the MATRICS study. Sleep 2020;43(9): »8, «Tu AY, Crawford MR, Dawson SC, ym. A randomized controlled trial of cognitive behavioral therapy for insomnia and PAP for obstructive sleep apnea and comorbid insomnia: effects on nocturnal sleep and »9.CBT-I is safe in COMISA, including in moderate and severe OSA, though close monitoring for transient increases in daytime sleepiness during initial sleep restriction is recommended «Sweetman A, McEvoy RD, Smith S, ym. The effect of cognitive and behavioral therapy for insomnia on week-to-week changes in sleepiness and sleep parameters in patients with comorbid insomnia and sleep »5. CBT-I also improves acceptance and adherence to positive airway pressure (PAP) therapy in COMISA, and combined treatment with CBT-I and PAP yields superior insomnia outcomes compared to PAP alone «Sweetman A, Lack L, Catcheside PG, ym. Cognitive and behavioral therapy for insomnia increases the use of continuous positive airway pressure therapy in obstructive sleep apnea participants with comor»10, «Ragnoli B, Pochetti P, Raie A, ym. Comorbid Insomnia and Obstructive Sleep Apnea (COMISA): Current Concepts of Patient Management. Int J Environ Res Public Health 2021;18(17): »7, «Ong JC, Crawford MR, Dawson SC, ym. A randomized controlled trial of CBT-I and PAP for obstructive sleep apnea and comorbid insomnia: main outcomes from the MATRICS study. Sleep 2020;43(9): »8, «Tu AY, Crawford MR, Dawson SC, ym. A randomized controlled trial of cognitive behavioral therapy for insomnia and PAP for obstructive sleep apnea and comorbid insomnia: effects on nocturnal sleep and »9. CBT-I may also reduce OSA severity, potentially through increased N3 sleep, though it does not alter OSA endotype traits «Ong JC, Crawford MR, Wallace DM. Sleep Apnea and Insomnia: Emerging Evidence for Effective Clinical Management. Chest 2021;159(5):2020-2028 »4.The Department of Veterans Affairs guideline recommends CBT-I as first-line therapy for insomnia in COMISA, delivered via individual, group, or digital modalities «Sharafkhaneh A, Thomas A, Ulmer C, ym. The Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea (Insomnia/OSA). Department of Veterans Affairs. 20253»6. Digital CBT-I is effective and accessible, with sustained improvements in insomnia, depression, anxiety, and sleepiness «Sweetman A, Richardson C, Smith A, ym. The Effect of Digital Cognitive Behavioural Therapy for Insomnia in People With Co-Morbid Insomnia and Sleep Apnoea (COMISA): A Pilot Randomised Controlled Trial»2. Multidisciplinary, patient-centered care integrating CBT-I and PAP is recommended to optimize outcomes in COMISA «Ong JC, Crawford MR, Wallace DM. Sleep Apnea and Insomnia: Emerging Evidence for Effective Clinical Management. Chest 2021;159(5):2020-2028 »4, «Ragnoli B, Pochetti P, Raie A, ym. Comorbid Insomnia and Obstructive Sleep Apnea (COMISA): Current Concepts of Patient Management. Int J Environ Res Public Health 2021;18(17): »7.CBT-I should be considered the standard of care for insomnia in COMISA, with strong evidence supporting its efficacy, safety, and role in improving PAP adherence and sleep outcomes. «Sweetman A, Farrell S, Wallace DM, ym. The effect of cognitive behavioural therapy for insomnia in people with comorbid insomnia and sleep apnoea: A systematic review and meta-analysis. J Sleep Res 20»1, «Sweetman A, Richardson C, Smith A, ym. The Effect of Digital Cognitive Behavioural Therapy for Insomnia in People With Co-Morbid Insomnia and Sleep Apnoea (COMISA): A Pilot Randomised Controlled Trial»2, «Sweetman A, Lechat B, Catcheside PG, ym. Polysomnographic Predictors of Treatment Response to Cognitive Behavioral Therapy for Insomnia in Participants With Co-morbid Insomnia and Sleep Apnea: Seconda»3, «Ong JC, Crawford MR, Wallace DM. Sleep Apnea and Insomnia: Emerging Evidence for Effective Clinical Management. Chest 2021;159(5):2020-2028 »4, «Sweetman A, McEvoy RD, Smith S, ym. The effect of cognitive and behavioral therapy for insomnia on week-to-week changes in sleepiness and sleep parameters in patients with comorbid insomnia and sleep »5, «Sharafkhaneh A, Thomas A, Ulmer C, ym. The Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea (Insomnia/OSA). Department of Veterans Affairs. 20253»6, «Ragnoli B, Pochetti P, Raie A, ym. Comorbid Insomnia and Obstructive Sleep Apnea (COMISA): Current Concepts of Patient Management. Int J Environ Res Public Health 2021;18(17): »7, «Ong JC, Crawford MR, Dawson SC, ym. A randomized controlled trial of CBT-I and PAP for obstructive sleep apnea and comorbid insomnia: main outcomes from the MATRICS study. Sleep 2020;43(9): »8, «Tu AY, Crawford MR, Dawson SC, ym. A randomized controlled trial of cognitive behavioral therapy for insomnia and PAP for obstructive sleep apnea and comorbid insomnia: effects on nocturnal sleep and »9, «Sweetman A, Lack L, Catcheside PG, ym. Cognitive and behavioral therapy for insomnia increases the use of continuous positive airway pressure therapy in obstructive sleep apnea participants with comor»10.

References

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  9. Tu AY, Crawford MR, Dawson SC, ym. 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 «PMID: 34648425»PubMed
  10. Sweetman A, Lack L, Catcheside PG, ym. Cognitive and behavioral therapy for insomnia increases the use of continuous positive airway pressure therapy in obstructive sleep apnea participants with comorbid insomnia: a randomized clinical trial. Sleep 2019;42(12): «PMID: 31403168»PubMed