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Randomized Controlled Trial
. 2021 Mar 1;17(3):545-554.
doi: 10.5664/jcsm.8944.

Effect of depression, anxiety, and stress symptoms on response to cognitive behavioral therapy for insomnia in patients with comorbid insomnia and sleep apnea: a randomized controlled trial

Alexander Sweetman  1 , Leon Lack  1   2 , R Doug McEvoy  1   3 , Peter G Catcheside  1 , Nick A Antic  1   3 , Ching Li Chai-Coetzer  1   3 , James Douglas  4 , Amanda O'Grady  1 , Nicola Dunn  4 , Jan Robinson  4 , Denzil Paul  1 , Simon Smith  5
Affiliations
Randomized Controlled Trial

Effect of depression, anxiety, and stress symptoms on response to cognitive behavioral therapy for insomnia in patients with comorbid insomnia and sleep apnea: a randomized controlled trial

Alexander Sweetman et al. J Clin Sleep Med. .

Abstract

Study objectives: Patients with comorbid insomnia and sleep apnea (COMISA) report increased severity of depression, anxiety, and stress symptoms compared to patients with either insomnia or sleep apnea alone. Although cognitive behavioral therapy for insomnia (CBTi) is an effective treatment for COMISA, previous research suggests a reduced response to CBTi by patients with insomnia and depression, anxiety, and stress symptoms. Therefore, we used randomized controlled trial data to investigate the impact of depression, anxiety, and stress symptoms before treatment on changes in insomnia after CBTi vs control in patients with COMISA.

Methods: 145 patients with COMISA (insomnia as defined by the International Classification of Sleep Disorders, third edition and apnea-hypopnea index ≥ 15 events/h) were randomized to CBTi (n = 72) or no-treatment control (n = 73). One-week sleep diaries and standardized questionnaire measures of insomnia, sleepiness, fatigue, depression, anxiety, and stress were completed pretreatment and posttreatment. Mixed models were used to examine interactions between depression, anxiety, and stress symptoms before treatment, intervention-group (CBTi, control), and time (pretreatment, posttreatment) on insomnia symptoms.

Results: Approximately half of this COMISA sample reported at least mild symptoms of depression (57%), anxiety (53%), and stress (48%) before treatment. Patients reporting greater depression, anxiety, and stress symptoms before treatment also reported increased severity of insomnia, daytime fatigue, and sleepiness. Improvements in questionnaire and diary-measured insomnia symptoms improved during CBTi and were not moderated by severity of depression, anxiety, or stress symptoms before treatment (all interaction P ≥ .11).

Conclusions: We found no evidence that symptoms of depression, anxiety, or stress impair the effectiveness of CBTi in improving insomnia symptoms in patients with COMISA. Patients with COMISA and comorbid symptoms of depression, anxiety, and stress should be referred for CBTi to treat insomnia and improve subsequent management of their obstructive sleep apnea.

Clinical trial registration: Registry: Australian New Zealand Clinical Trials Registry; Name: Treating comorbid insomnia with obstructive sleep apnea (COMISA) study: A new treatment strategy for patients with combined insomnia and sleep apnea; URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=365184; Identifier: ACTRN12613001178730.

Keywords: COMISA; anxiety; cognitive behavioral therapy; continuous positive airway pressure therapy; depression; insomnia; obstructive sleep apnea; stress.

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Conflict of interest statement

All authors have seen and approved this manuscript. Work for this study was performed at the Adelaide Institute for Sleep Health, Flinders University, and The Prince Charles Hospital, Queensland. This study was funded by a National Health and Medical Research Council Grant (1049591; Treating insomnia co-morbid with obstructive sleep apnoea: A randomized controlled clinical effectiveness trial). D.M. reports research funding support from Philips Respironics. P.C. received salary support via an Australian Research Council Future Fellowship (FT120100510) and reports research funding support from Philips Respironics via the CRC for Alertness, Safety and Productivity. D.P. no financial interests to throughout trial period, but began working for Philips Respironics (Melbourne, Australia) following completion of trial data collection. L.L. has received funding support from Re-timer (Re-timer Pty Ltd, Adelaide, Australia). D.M. Research equipment donations from ResMed and Air Liquide. P.G.C. equipment support from Philips Respironics and Air Liquide. C.L.C.C. reports previous equipment support from Philips Respironics and ResMed (ApneaLink devices and CPAP equipment). None of the other authors report conflicts of interest.

Figures

Figure 1
Figure 1. Study design, and patient recruitment and retention.
AHI = apnea-hypopnea index, CBTi = cognitive behavioral therapy for insomnia, CPAP = continuous positive airway pressure, ISI = Insomnia Severity Index, OSA50 = Obstructive Sleep Apnea screening questionnaire.
Figure 2
Figure 2. Changes in insomnia severity during treatment between intervention-group, time and depression severity before treatment (± confidence intervals).
The depression subscale was scored on a scale of 0 (lowest severity) to 42 (highest severity). Different insomnia severity change scores are modeled on pretreatment depression severity scores in increments of 10 (ie, 0, 10, 20, 30, and 40). CBTi = cognitive behavior therapy for insomnia.
Figure 3
Figure 3. Changes in sleep onset latency during treatment between intervention-group, time and anxiety severity before treatment (± confidence intervals).
The anxiety subscale was scored on a scale of 0 (lowest severity) to 42 (highest severity). CBTi = cognitive behavior therapy for insomnia.
Figure 4
Figure 4. Changes in sleep efficiency during treatment between intervention-group, time and stress severity before treatment (± confidence intervals).
The stress subscale was scored on a scale of 0 (lowest severity) to 42 (highest severity). CBTi = cognitive behavior therapy for insomnia.
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References

    1. Ohayon MM, Reynolds CF 3rd. Epidemiological and clinical relevance of insomnia diagnosis algorithms according to the DSM-IV and the International Classification of Sleep Disorders (ICSD). Sleep Med. 2009;10(9):952–960. 10.1016/j.sleep.2009.07.008 - DOI - PMC - PubMed
    1. Heinzer R, Vat S, Marques-Vidal P, et al. . Prevalence of sleep-disordered breathing in the general population: the HypnoLaus study. Lancet Respir Med. 2015;3(4):310–318. 10.1016/S2213-2600(15)00043-0 - DOI - PMC - PubMed
    1. Sweetman AM, Lack LC, Catcheside PG, et al. . Developing a successful treatment for co-morbid insomnia and sleep apnoea. Sleep Med Rev. 2017;33:28–38. 10.1016/j.smrv.2016.04.004 - DOI - PubMed
    1. Sweetman A, Lack L, Bastien C. Co-morbid insomnia and sleep apnea (COMISA): prevalence, consequences, methodological considerations, and recent randomized controlled trials. Brain Sci. 2019;9(12):371. 10.3390/brainsci9120371 - DOI - PMC - PubMed
    1. Krakow B, Melendrez D, Ferreira E, et al. . Prevalence of insomnia symptoms in patients with sleep-disordered breathing. Chest. 2001;120(6):1923–1929. 10.1378/chest.120.6.1923 - DOI - PubMed

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