A Randomized Controlled Trial of CBT-I and PAP for Obstructive Sleep Apnea and Comorbid Insomnia: Main Outcomes from the MATRICS Study

Overview

Journal Sleep

Publisher Oxford University Press

Specialty Psychiatry

Date 2020 Mar 15

PMID 32170307

Citations 24

Authors

Jason C Ong

Megan R Crawford

Spencer C Dawson

Louis F Fogg

Arlener D Turner

James K Wyatt

Maria I Crisostomo

Bantu S Chhangani

Clete A Kushida

Jack D Edinger

Sabra M Abbott

Roneil G Malkani

Hrayr P Attarian

Phyllis C Zee

Affiliations

Soon will be listed here.

Abstract

Study Objectives: To investigate treatment models using cognitive behavioral therapy for insomnia (CBT-I) and positive airway pressure (PAP) for people with obstructive sleep apnea (OSA) and comorbid insomnia.

Methods: 121 adults with OSA and comorbid insomnia were randomized to receive CBT-I followed by PAP, CBT-I concurrent with PAP, or PAP only. PAP was delivered following standard clinical procedures for in-lab titration and home setup and CBT-I was delivered in four individual sessions. The primary outcome measure was PAP adherence across the first 90 days, with regular PAP use (≥4 h on ≥70% of nights during a 30-day period) serving as the clinical endpoint. The secondary outcome measures were the Pittsburgh Sleep Quality Index (PSQI) and Insomnia Severity Index (ISI) with good sleeper (PSQI <5), remission (ISI <8), and response (ISI reduction from baseline >7) serving as the clinical endpoints.

Results: No significant differences were found between the concomitant treatment arms and PAP only on PAP adherence measures, including the percentage of participants who met the clinical endpoint. Compared to PAP alone, the concomitant treatment arms reported a significantly greater reduction from baseline on the ISI (p = .0009) and had a greater percentage of participants who were good sleepers (p = .044) and remitters (p = .008). No significant differences were found between the sequential and concurrent treatment models on any outcome measure.

Conclusions: The findings from this study indicate that combining CBT-I with PAP is superior to PAP alone on insomnia outcomes but does not significantly improve adherence to PAP.

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References

Gupta M, Knapp K . Cardiovascular and psychiatric morbidity in obstructive sleep apnea (OSA) with insomnia (sleep apnea plus) versus obstructive sleep apnea without insomnia: a case-control study from a Nationally Representative US sample. PLoS One. 2014; 9(3):e90021. PMC: 3943798. DOI: 10.1371/journal.pone.0090021. View

Ong J, Crisostomo M . The more the merrier? Working towards multidisciplinary management of obstructive sleep apnea and comorbid insomnia. J Clin Psychol. 2013; 69(10):1066-77. PMC: 3766499. DOI: 10.1002/jclp.21958. View

Wallace D, Vargas S, Schwartz S, Aloia M, Shafazand S . Determinants of continuous positive airway pressure adherence in a sleep clinic cohort of South Florida Hispanic veterans. Sleep Breath. 2012; 17(1):351-63. DOI: 10.1007/s11325-012-0702-6. View

Choi S, Joo E, Lee Y, Bong Hong S . Suicidal ideation and insomnia symptoms in subjects with obstructive sleep apnea syndrome. Sleep Med. 2015; 16(9):1146-50. DOI: 10.1016/j.sleep.2015.04.026. View

Fung C, Martin J, Josephson K, Fiorentino L, Dzierzewski J, Jouldjian S . Efficacy of Cognitive Behavioral Therapy for Insomnia in Older Adults With Occult Sleep-Disordered Breathing. Psychosom Med. 2016; 78(5):629-39. PMC: 4891271. DOI: 10.1097/PSY.0000000000000314. View

Bjornsdottir E, Janson C, Sigurdsson J, Gehrman P, Perlis M, Juliusson S . Symptoms of insomnia among patients with obstructive sleep apnea before and after two years of positive airway pressure treatment. Sleep. 2013; 36(12):1901-9. PMC: 3825440. DOI: 10.5665/sleep.3226. View

Saconi B, Yang H, Watach A, Sawyer A . Coping Processes, Self-Efficacy, and CPAP Use in Adults With Obstructive Sleep Apnea. Behav Sleep Med. 2018; 18(1):68-80. PMC: 6535371. DOI: 10.1080/15402002.2018.1545651. View

Dzierzewski J, Wallace D, Wohlgemuth W . Adherence to Continuous Positive Airway Pressure in Existing Users: Self-Efficacy Enhances the Association between Continuous Positive Airway Pressure and Adherence. J Clin Sleep Med. 2015; 12(2):169-76. PMC: 4751420. DOI: 10.5664/jcsm.5478. View

Crawford M, Chirinos D, Iurcotta T, Edinger J, Wyatt J, Manber R . Characterization of Patients Who Present With Insomnia: Is There Room for a Symptom Cluster-Based Approach?. J Clin Sleep Med. 2017; 13(7):911-921. PMC: 5482583. DOI: 10.5664/jcsm.6666. View

10.

Krakow B, Melendrez D, Lee S, Warner T, Clark J, Sklar D . Refractory insomnia and sleep-disordered breathing: a pilot study. Sleep Breath. 2004; 8(1):15-29. DOI: 10.1007/s11325-004-0015-5. View

11.

Wickwire E, Smith M, Birnbaum S, Collop N . Sleep maintenance insomnia complaints predict poor CPAP adherence: A clinical case series. Sleep Med. 2010; 11(8):772-6. DOI: 10.1016/j.sleep.2010.03.012. View

12.

Buysse D, Reynolds 3rd C, Monk T, BERMAN S, Kupfer D . The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psychiatry Res. 1989; 28(2):193-213. DOI: 10.1016/0165-1781(89)90047-4. View

13.

Gagnadoux F, Le Vaillant M, Paris A, Pigeanne T, Leclair-Visonneau L, Bizieux-Thaminy A . Relationship Between OSA Clinical Phenotypes and CPAP Treatment Outcomes. Chest. 2016; 149(1):288-90. DOI: 10.1016/j.chest.2015.09.032. View

14.

Cistulli P, Armitstead J, Pepin J, Woehrle H, Nunez C, Benjafield A . Short-term CPAP adherence in obstructive sleep apnea: a big data analysis using real world data. Sleep Med. 2019; 59:114-116. PMC: 6589354. DOI: 10.1016/j.sleep.2019.01.004. View

15.

Baratta F, Pastori D, Bucci T, Fabiani M, Fabiani V, Brunori M . Long-term prediction of adherence to continuous positive air pressure therapy for the treatment of moderate/severe obstructive sleep apnea syndrome. Sleep Med. 2018; 43:66-70. DOI: 10.1016/j.sleep.2017.09.032. View

16.

Saaresranta T, Hedner J, Bonsignore M, Riha R, McNicholas W, Penzel T . Clinical Phenotypes and Comorbidity in European Sleep Apnoea Patients. PLoS One. 2016; 11(10):e0163439. PMC: 5049787. DOI: 10.1371/journal.pone.0163439. View

17.

Krakow B, McIver N, Obando J, Ulibarri V . Changes in insomnia severity with advanced PAP therapy in patients with posttraumatic stress symptoms and comorbid sleep apnea: a retrospective, nonrandomized controlled study. Mil Med Res. 2019; 6(1):15. PMC: 6507057. DOI: 10.1186/s40779-019-0204-y. View

18.

Morin C, Belleville G, Belanger L, Ivers H . The Insomnia Severity Index: psychometric indicators to detect insomnia cases and evaluate treatment response. Sleep. 2011; 34(5):601-8. PMC: 3079939. DOI: 10.1093/sleep/34.5.601. View

19.

Krell S, Kapur V . Insomnia complaints in patients evaluated for obstructive sleep apnea. Sleep Breath. 2005; 9(3):104-10. DOI: 10.1007/s11325-005-0026-x. View

20.

Sivertsen B, Bjornsdottir E, Overland S, Bjorvatn B, Salo P . The joint contribution of insomnia and obstructive sleep apnoea on sickness absence. J Sleep Res. 2012; 22(2):223-30. DOI: 10.1111/j.1365-2869.2012.01055.x. View