Insomnia with sleep apnoea: what online therapy changed in a trial

At the sleep medicine centre of West China Hospital in Chengdu, 88 adults who had both insomnia and obstructive sleep apnoea were randomly assigned to six weekly online sessions of cognitive behavioural therapy for insomnia guided by a clinician, or to sleep hygiene education alone. Three months later, insomnia severity had fallen by 9.5 points on a 28-point scale in the therapy group and by 4.0 points in the comparison group. The results were published online on 29 October 2026 in the American Journal of Respiratory and Critical Care Medicine by Shi, Tang and colleagues.

Two sleep problems in one person

In obstructive sleep apnoea, the throat repeatedly narrows or closes during sleep and breathing pauses. Insomnia, trouble falling or staying asleep, often comes with it; researchers call the combination COMISA. Cognitive behavioural therapy for insomnia, known as CBT-I, is the treatment the American Academy of Sleep Medicine recommends for chronic insomnia in adults. In people who also have apnoea, there was a specific concern about its safety and how widely it could be offered, and the authors set out to test a digital version of it in this group.

Earlier studies pointed the same way. A 2023 systematic review of 21 studies with 1,040 participants with COMISA found that CBT-I was associated with a large improvement in insomnia severity in a meta-analysis of nine of them. A 2019 Australian trial in 145 people with apnoea and insomnia found that four sessions of CBT-I before starting a CPAP machine raised average nightly CPAP use by 61 minutes. Researchers in the field describe the therapy as effective but hard to access for these patients.

How the trial was run

The online programme had six weekly sessions: sleep restriction (temporarily limiting time in bed), sleep hygiene, stimulus control, cognitive restructuring and relapse prevention, with guidance from a clinician. The comparison group received sleep hygiene education only. Outcomes were assessed by people who did not know the group assignment, at the start, after six weeks of treatment and three months later. The main measures were two questionnaires, the Insomnia Severity Index and the Pittsburgh Sleep Quality Index. Apnoea severity was measured by overnight polysomnography in the laboratory as a secondary outcome.

What changed

At three months, in the analysis that kept every randomised participant in their group:

• insomnia severity fell by 9.5 points with the therapy and by 4.0 with sleep hygiene education;

• the sleep quality score improved by 4.9 versus 1.8 points;

• daytime sleepiness on the Epworth scale fell by 3.4 versus 1.0 points.

At the end of the six weeks, the apnoea–hypopnoea index, the number of breathing pauses and shallow-breathing episodes per hour of sleep, fell by 6.0 per hour in the therapy group and rose by 2.0 per hour in the comparison group. The authors also report gains on tests of executive function and metacognition.

The weeks when sleepiness rose

Daytime sleepiness in the therapy group increased temporarily in weeks two to four. The authors report no functional impairment and no sleepiness-related adverse events. The programme in this trial was guided by clinicians; self-guided apps were not tested.

Where the evidence stops

The trial was small, 88 people at one centre in China, and lasted three months. The comparison was sleep hygiene education, not CPAP or another apnoea treatment, so the trial does not show that the programme can replace treatment for apnoea. The drop in the apnoea index was a secondary outcome reported at the end of treatment; the published summary does not say whether it held at three months, and it does not give starting apnoea severity, so it is hard to judge what six events per hour meant for these participants. The summary also does not explain why the index changed.

What to discuss with your doctor

For people who sleep poorly and also have diagnosed sleep apnoea, this trial adds to earlier evidence that insomnia in this group can be treated in its own right. Whether CBT-I, including a clinician-guided online programme, fits alongside apnoea treatment, and how to manage the temporary sleepiness it can bring, is worth discussing with a sleep specialist.

This article is for information only and does not replace a consultation with a doctor.

Sources

• Shi Y, Feng X, Chen Z, et al. Clinician-guided digital CBT-I improves sleep quality and apnea severity in patients with co-morbid insomnia and OSA: A Double-Blind, Randomized Clinical Trial. Am J Respir Crit Care Med, 2026, published online 29 October. PubMed 42958645, doi:10.1093/ajrccm/aamag567

• Trial registration: Chinese Clinical Trial Registry ChiCTR2500099854

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• Sweetman A, Lack L, Catcheside PG, et al. Cognitive and behavioral therapy for insomnia increases the use of continuous positive airway pressure therapy in obstructive sleep apnea participants with comorbid insomnia: a randomized clinical trial. Sleep, 2019;42(12):zsz178. PubMed 31403168

• Sweetman A, Richardson C, Smith A, Reynolds C. The Effect of Digital Cognitive Behavioural Therapy for Insomnia in People With Co-Morbid Insomnia and Sleep Apnoea (COMISA): A Pilot Randomised Controlled Trial. J Sleep Res, 2026;35(1):e70114. PubMed 40557787

• Edinger JD, Arnedt JT, Bertisch SM, et al. Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med, 2021;17(2):255–262. PubMed 33164742