Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep MedicineOct 29, 2020

How depression, anxiety, and stress symptoms relate to response to cognitive behavioral therapy for insomnia in patients with both insomnia and sleep apnea

Circadian Biology Weekly Brief ↗PubMed ↗DOI ↗

Updated Apr 3, 2026

Abstract

Approximately 57% of patients with comorbid insomnia and sleep apnea reported at least mild symptoms of depression before treatment.

Patients with comorbid insomnia and sleep apnea (COMISA) reported increased severity of insomnia, daytime fatigue, and sleepiness associated with greater symptoms of depression, anxiety, and stress before treatment.
Cognitive behavioral therapy for insomnia (CBTi) led to improvements in insomnia symptoms regardless of the severity of depression, anxiety, or stress symptoms before treatment.
The effectiveness of CBTi in improving insomnia symptoms was not moderated by pre-treatment levels of depression, anxiety, or stress.
Referral for CBTi is suggested for patients with COMISA experiencing comorbid symptoms of depression, anxiety, and stress to address insomnia and enhance management of obstructive sleep apnea.

Simplified

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.

Funding

Competing interests

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.

PubMed

How depression, anxiety, and stress symptoms relate to response to cognitive behavioral therapy for insomnia in patients with both insomnia and sleep apnea

Abstract

Funding

Competing interests

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