CBT-I With CPAP: Better Insomnia Scores, Mixed Machine-Use Results

If you have obstructive sleep apnea and still struggle to fall or stay asleep, ask the sleep clinic whether insomnia needs its own assessment. Trials of cognitive behavioral therapy for insomnia, CBT-I, have examined adding that treatment to positive airway pressure, or PAP. Their findings distinguish insomnia improvement from hours of machine use.¹²

Four sessions before CPAP: the 2019 trial

Sweetman and colleagues¹ randomized 145 people with insomnia and at least moderate sleep apnea to four CBT-I sessions or usual care before CPAP. By the six-month assessment, the CBT-I group averaged 61 minutes more nightly CPAP use than the comparison group, with a 95% confidence interval of 9–113 minutes. Insomnia-severity improvement also favored CBT-I.¹

The 61 minutes measures additional machine use. It is not an extra hour of sleep, a guarantee for each patient or proof that every person should postpone CPAP for therapy.

Before or alongside PAP: MATRICS

The 2020 MATRICS trial² randomized 121 adults, analyzing 118, to CBT-I before PAP, CBT-I alongside PAP, or PAP alone. Average age was 50; 53.4% were women.²

Adding CBT-I improved insomnia-severity outcomes, but did not significantly improve PAP adherence over the first 90 days. Starting CBT-I first did not significantly outperform starting it alongside PAP on the measured outcomes.²

MATRICS included mild apnea as well as more severe disease; the earlier trial required at least moderate apnea. These studies do not establish why their machine-use results differed.¹²

The distinction matters at follow-up. Feeling less distressed about wakefulness and using PAP longer are separate outcomes. Ask the clinic to review both rather than assuming improvement in one proves improvement in the other.

Treatment timing needs a safety review

MATRICS excluded people whose apnea required immediate treatment and those with severe daytime sleepiness. Its treatment schedules cannot simply be transferred to someone who is dangerously sleepy or has urgent breathing-treatment needs.²

The AASM recommends multicomponent CBT-I for chronic insomnia and advises against sleep-hygiene tips as the sole treatment. It also notes that treatment can initially cause fatigue, sleepiness and attention difficulties. Sleep restriction, one possible component, may be unsuitable in certain circumstances, including high-risk work, vulnerability to mania or poorly controlled seizures.³

Do not shorten your sleep window or delay prescribed PAP on your own. Ask how the clinician will adapt insomnia care to your daytime alertness, work and medical history. Report drowsiness while driving promptly. NHLBI advises against driving when tired or sleepy and recommends using prescribed PAP for all sleep, including naps. It also advises contacting the provider about mask leaks, claustrophobia or difficulty falling or staying asleep.⁴

Bring separate questions about the machine and the insomnia

At the next review, ask:

• Does my pattern meet insomnia criteria, and can you refer me for CBT-I?
• Should treatment begin alongside PAP or follow another schedule in my circumstances?
• Who can help with mask discomfort or other equipment problems while insomnia is being treated?
• Which diary measures and machine data will we review, and when?

Did I Do That in My Sleep? explains CBT-I in “What CBT-I Actually Addresses” and describes questions about access to trained care. Use that section to prepare for a coordinated treatment discussion.