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. 2025 Mar 14;29(2):129.
doi: 10.1007/s11325-025-03298-z.

Determinants of treatment response to cognitive behavioral therapy in veterans presenting with comorbid insomnia and sleep apnea

Ali A El-Solh  1   2   3 , Amber Martinson  4 , Parveen Attai  5   6 , Gregory Homish  7 , Keziah Aibangbee  5   6 , Erin Gould  5   6
Affiliations

Determinants of treatment response to cognitive behavioral therapy in veterans presenting with comorbid insomnia and sleep apnea

Ali A El-Solh et al. Sleep Breath. .

Abstract

Purpose: Although cognitive behavioral therapy for insomnia (CBT-I) is considered the preferred treatment for insomnia in patients with comorbid insomnia and obstructive sleep apnea (COMISA), the remission rate with CBT-I is generally considered lower than in insomnia-only populations. There is also a sizable variability in individual treatment responses. Due to the limited availability of CBT-I, we sought to identify specific clinical attributes that predict benefit from Brief Behavioral Therapy for Insomnia (BBTI)-an adaptation of CBT-I-in patients with COMISA.

Methods: We conducted a retrospective analysis of the National Veterans Health Administration (VHA) electronic medical records covering veterans diagnosed with COMISA between January 2021 and December 2023. Insomnia Severity Index (ISI) scores were recorded at baseline and after 12±1 weeks after BBTI. A positive response to BBTI was defined as a reduction in ISI score of ≥ 8 from baseline. A multivariate generalized linear model analysis was performed to delineate predictive factors of BBTI responsiveness.

Results: 131 eligible cases received BBTI over 6 weeks, 56 (43%) of whom did not respond. Non-whites (OR 3.5, 95% CI [1.4, 8.8]) and shorter sleep time (OR 0.98, 95% CI [0.98, 0.99] were independent predictors of blunted response to BBTI. These findings remained true even when depression and AHI were forced into the regression model. Patients with a total sleep duration of < 4.1 h were at greatest risk of being nonresponsive to BBTI.

Conclusion: These findings indicate that identifying insomnia phenotypes in patients with COMISA would help deliver personalized care while maximizing BBTI treatment resources.

Keywords: Cognitive behavioral therapy; Continuous positive airway pressure; Insomnia; Pharmacotherapy; Sleep apnea.

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Conflict of interest statement

Declarations. Ethical approval: All procedures performed in this study involving human participants were in accordance with the ethical standards of the U.S. Department of Veterans Affairs and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The study was approved by the Research and Development of the VA Western New York. Disclaimer: The views expressed in this article are solely those of the authors and do not reflect an endorsement by or the official policy of the U.S. Army, the Department of Defense (DoD), the Department of Veterans Affairs (VA), or the U.S. Government. This material is the result of work supported with resources and the use of facilities at the VA Western New York Health Care System. Conflicts of interest: No potential conflict of interests by the authors. All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.

Figures

Fig. 1
Fig. 1
Flow diagram depicting the selection of the study population
Fig. 2
Fig. 2
A receiver operator characteristic curve for total sleep time. AUC = area under the curve; TST = total sleep time
Fig. 3
Fig. 3
Response and remission rates based on optimal total sleep time
See this image and copyright information in PMC

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