Insomnia and Sleep Apnea: How to Treat Both at Once

I previously wrote about why more people are getting diagnosed with comorbid insomnia and sleep apnea (COMISA). The reality of how dangerous COMISA can be is sobering.

Fortunately, the right combination of treatments can help.

Challenges to treating COMISA

When describing the available treatments, I will mostly reference the gold-standard treatments of cognitive behavioral therapy for insomnia (CBTI) and positive airway pressure masks (PAPs) for obstructive sleep apnea (OSA). While other treatments exist for both conditions, these 2 are the most researched and empirically supported.¹

Reluctance to therapy

The relationship between insomnia and sleep apnea is complicated, which can also make treatment challenging. After dealing with poor sleep for months or years, people with insomnia can become protective of the little sleep they're able to obtain. Sleep becomes such a precious commodity that we avoid doing anything that can disrupt it.¹

This includes anything that makes us physically uncomfortable, including wearing a PAP. People living with COMISA may be reluctant to try a PAP. They also tend to use the mask for fewer hours per night than people without insomnia.¹

Stimulus control and sleep restriction

It can also be difficult for people with COMISA to apply behavioral treatments for insomnia, like CBTI. Two major techniques in CBTI include stimulus control:¹

• Getting out of bed if you're not asleep
• Sleep restriction, meaning keeping a strict bed and wake time

If you use a PAP, removing the mask and getting out of bed can be cumbersome. Same with getting back into bed and reattaching your mask. And if you have excessive daytime sleepiness due to OSA, restricting your sleep too much can become dangerous.

How treatment works

While there are several challenges to treating COMISA, treatment works. Evidence suggests that both conditions need to be targeted.¹

To put it another way, treating insomnia alone will not "cure" OSA, and vice versa. That said, treating each condition may lead to some improvement in the other.¹

Improving your treatment outcomes

Researchers have been studying how to improve treatment outcomes for people living with COMISA. They provide a few suggestions.

CBTI can make PAP use more comfortable. One study found that people whose insomnia improved following CBTI were more likely to use their PAP. This makes sense if we go back to the point made above: People with insomnia may "protect" their sleep by avoiding discomfort. But if sleep becomes more predictable and restorative, they may become more tolerant to the initial discomfort of a PAP mask. Therefore, it may be helpful to start insomnia treatment even before the person receives their PAP.¹

Another reason to recommend starting CBTI before CPAP is that there is often a delay between getting diagnosed with OSA and receiving and titrating one's PAP. This may leave a natural 3- to 5-week window during which the person can begin behavioral treatment for insomnia while they wait for their equipment. That time frame also allows people to engage in the majority of the stimulus control and sleep restriction portions of CBTI. That way, they will need to get out of bed less frequently by the time their PAP arrives.¹

The person's preferences should guide treatment. That may seem like an obvious statement, but it's worth highlighting. Most of the time, our motivation to do difficult things is affected by how uncomfortable we are with the status quo. Interventions like CBTI and PAP are often challenging at first. And trying to do both at once can be even harder.¹

Considering motivation and personal priorities

Motivation is crucial, and each one of us has a different set of priorities. For some of us, falling asleep quickly is most important. For others, fear of the long-term effects of OSA is a bigger motivator.

Ask yourself what is causing you the most distress right now and what you feel most motivated to tackle first. Then harness that motivation and fully engage in the right treatment. As you make progress, you may find that you have more energy and patience to start engaging in the other interventions. Setting realistic expectations for yourself (including patience!) will help you get to the finish line.

So, you have COMISA, share your treatment success and failures in a comment below.