. Author manuscript; available in PMC: 2024 Jan 1.

Published in final edited form as: Int Forum Allergy Rhinol. 2023 Mar 30;13(7):1061–1482. doi: 10.1002/alr.23079

TABLE VIII.A.5.i.

Insomnia treatment and PAP adherence

Study	Year	LOE	Study design	Study groups	Clinical endpoint	Conclusion
Sweetman et al.¹¹⁸⁹	2019	1b	Systematic review	4 RCTs considered	CPAP adherence, insomnia outcomes: Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index (PSQI), Bergen Insomnia Scale (BSI)	RCTs provide tentative support for the effect of therapist-administered CBTi in improving insomnia symptoms and increasing CPAP use in OSA patients with comorbid insomnia; CBTi delivered by trained therapists may be more effective than self-administered CBTi.
Ong et al.¹¹⁸⁸	2020	1b	RCT	121 adults with OSA and comorbid insomnia randomized to: 1) CBTi followed by PAP, 2) CBTi concurrent with PAP, or 3) PAP only	Apnea diagnosed with PSG; Primary Outcome: 90-day PAP adherence; Secondary outcomes: PSQI, ISI	No significant group differences in PAP adherence between groups; compared to PAP alone, the concomitant treatment arms led to greater improvement in ISI.
Alessia et al.¹¹⁸⁷	2020	1b	RCT	125 with comorbid insomnia and newly-diagnosed OSA by PSG (AHI≥15 events/h) randomized to: 1) 5-weekly sessions integrating CBTi with a PAP adherence program provided by a “sleep coach” or 2) 5-weekly sleep education control sessions	Apnea diagnosed with PSG (AHI ≥ 15 events/h); PSQI, 7-day sleep diary, 7-day actigraphy; objective PAP use, ISI, Epworth Sleepiness Scale (ESS), Functional Outcomes of Sleep Questionnaire-10 (FOSQ-10).	Six months after CBTi intervention, 90-day PAP use was increased by 0.9 h/night. CBTi led to greater improvement in PSQI, ISI, ESS, FOSQ-10, diary sleep onset latency, and sleep efficiency; and actigraphic sleep efficiency.
Sweetman et al.^{957,1190–1191}	2019, 2020	1b	RCT	145 patients with insomnia and untreated OSA randomized to: 1) a four-session CBTi programme followed by CPAP or 2) no treatment followed by CPAP	Insomnia diagnosed with ICSD-3; apnea diagnosed with PSG (AHI ≥ 15); Sleepiness evaluated with ESS, ISI, Dysfunctional Beliefs and Attitudes about Sleep Questionnaire Primary outcome: AHI	The CBTi group showed a 7.5 event/h greater AHI difference compared to control (p = 0.012), a greater reduction in total number of nocturnal awakenings (p = 0.031), and higher initial CPAP treatment acceptance (99% vs. 89%; p = 0.034). By 6 months after intervention, the CBTi group had 61 min greater average nightly adherence to subsequent CPAP (p = 0.023) and greater improvement of global insomnia severity, and dysfunctional sleep-related cognitions (p < 0.001)
Bjorvatn et al.¹¹⁹²	2018	1b	RCT	164 patients with HSAT-based OSA diagnosis randomized along with CPAP to: 1) a self-help book for insomnia or 2) sleep hygiene advice	BIS, ISI Apnea: AHI ≥ 5 events/h	No differences were found between groups; BIS and ISI improved significantly in both groups.