Prospective Randomized Study of Patients with Insomnia and Mild Sleep Disordered Breathing

COMORBID INSOMNIA IS COMMON AND ASSOCIATED SYNDROMES CAN OFTEN BE UNRECOGNIZED AND UNTREATED. THE ASSOCIATION BETWEEN INSOMNIA and obstructive sleep apnea (OSA) has been well recognized1 with approximately 50% to 55% of patients with OSA presenting with complaints of insomnia.2–4 Insomnia complaints have also been seen more commonly in patients with mild sleep disordered breathing (SDB).4 Women with SDB may present more often with insomnia features compared to men. Patients with SDB and insomnia appear to suffer less from hypoxia and daytime sleepiness than patients with classic sleep apnea commonly seen in overweight individuals.3,5 As mild SDB may not be associated with chronic snoring, particularly in premenopausal women, the SDB may be ignored while the chronic insomnia is treated pharmacologically with variable success and incomplete resolution of the daytime complaints. Even when polysomnography is performed (a rare event in the presence of insomnia complaint), arbitrary decisions are taken to treat the SDB when the selected index of severity (apnea-hypopnea index [AHI]) is above a value of 10 or 15 events/hour. This has lead to inappropriate patient care and secondary complications associated with chronic nocturnal sleep disturbances—mainly depression.5 The most common treatment options for OSA consist of surgery, continuous positive airway pressure (CPAP), or surgery and oral appliance use. Cognitive behavioral therapy (CBT-I) has been shown to have the best long-term outcome in patients with chronic insomnia.6–8 The best management strategy for patients with combined insomnia and OSA remains unclear.5 In this prospective crossover study, we evaluated the impact of primary management of OSA with surgery followed by cognitive-behavior therapy for insomnia (CBT-I) versus primary management of insomnia with CBT-I followed by treatment of OSA on subjective and objective measures of sleep quality. CBT-I treatment is not always necessarily available at the time of diagnosis, and patients may have to deal with a long waiting list. Furthermore, nasal CPAP is not necessarily the treatment of choice for patients with primary insomnia complaints who also have mild OSA. As an alternative, many patients may request trials with dental devices, surgical approach, or both treatments. At the Stanford Sleep Disorders clinic, we recognize that the first-line treatment for insomnia when it occurs comorbidly with SDB, has not been standardized. Because of the extended wait for any form of treatment in our setting, we suggested that these patients consider either a non-drug treatment approach (CBT-I), or treatment for OSA of their choice as the initial treatment, followed by another treatment with after a recovery period. Many patients refused this approach and requested treatment of either insomnia or OSA but not both in sequence, or requested pharmacologic treatment for insomnia. A minority of patients expressed interest in undergoing both treatments sequentially. As we had no clear indication which treatment should be applied first, these patients were randomized. The main objective of this study was to investigate the impact of the sequence of applied treatments on qualitative and quantitative sleep variables, by treating insomnia or OSA first.