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Cognitive behavioural therapy for insomnia reduces sleep apnoea severity: a randomised controlled trial

Alexander Sweetman, Leon Lack, R. Doug McEvoy, Nick A. Antic, Simon Smith, Ching Li Chai-Coetzer, James Douglas, Amanda O'Grady, Nicola Dunn, Jan Robinson, Denzil Paul, Danny Eckert, Peter G. Catcheside
ERJ Open Research 2020 6: 00161-2020; DOI: 10.1183/23120541.00161-2020
Alexander Sweetman
1The Adelaide Institute for Sleep Health: a Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Adelaide, Australia
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  • For correspondence: alexander.sweetman@flinders.edu.au
Leon Lack
1The Adelaide Institute for Sleep Health: a Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Adelaide, Australia
2The Adelaide Institute for Sleep Health: a Centre of Research Excellence, College of Education Psychology and Social Work, Flinders University, Adelaide, Australia
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R. Doug McEvoy
1The Adelaide Institute for Sleep Health: a Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Adelaide, Australia
3Sleep Health Service, Repatriation General Hospital and Respiratory and Sleep Services, Southern Adelaide Local Health Network, Adelaide, Australia
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Nick A. Antic
1The Adelaide Institute for Sleep Health: a Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Adelaide, Australia
3Sleep Health Service, Repatriation General Hospital and Respiratory and Sleep Services, Southern Adelaide Local Health Network, Adelaide, Australia
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Simon Smith
4Institute for Social Science Research, The University of Queensland, Brisbane, Australia
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Ching Li Chai-Coetzer
1The Adelaide Institute for Sleep Health: a Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Adelaide, Australia
3Sleep Health Service, Repatriation General Hospital and Respiratory and Sleep Services, Southern Adelaide Local Health Network, Adelaide, Australia
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James Douglas
5Thoracic Program, The Prince Charles Hospital, Brisbane, Australia
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Amanda O'Grady
1The Adelaide Institute for Sleep Health: a Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Adelaide, Australia
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Nicola Dunn
5Thoracic Program, The Prince Charles Hospital, Brisbane, Australia
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Jan Robinson
5Thoracic Program, The Prince Charles Hospital, Brisbane, Australia
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Denzil Paul
1The Adelaide Institute for Sleep Health: a Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Adelaide, Australia
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Danny Eckert
1The Adelaide Institute for Sleep Health: a Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Adelaide, Australia
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Peter G. Catcheside
1The Adelaide Institute for Sleep Health: a Centre of Research Excellence, College of Medicine and Public Health, Flinders University, Adelaide, Australia
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  • FIGURE 1
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    FIGURE 1

    Flow diagram indicating patient screening, recruitment, randomisation and follow-up. Missing sleep study data occurred in one cognitive behavioural therapy for insomnia (CBTi) study pre-treatment, and five CBTi and two control studies post-treatment (there were no significant between-group differences in rates of missing sleep study data pre- or post-treatment; both Fisher's exact p>0.05). 71 CBTi and 73 control patients had available sleep study data for mixed model analyses. ISI: insomnia severity index; OSA50: obstructive sleep apnoea 50 questionnaire; AHI: apnoea–hypopnoea index; CPAP: continuous positive airway pressure.

  • FIGURE 2
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    FIGURE 2

    Changes in apnoea–hypopnoea index (AHI) from pre- to post-treatment between groups, sleep stage and posture. Data are presented as mean±sem. CBTi: cognitive behavioural therapy for insomnia.

  • FIGURE 3
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    FIGURE 3

    Mean apnoea–hypopnoea index (AHI) and arousal index by sleep stage and sleep posture (collapsed over intervention group and time). Data are presented as mean (95% confidence interval).

Tables

  • Figures
  • TABLE 1

    Polysomnographic sleep study variables pre- and post-treatment, and between-group differences pre- and during treatment

    CBTiControlPre-treatment p-valueDuring treatment
    Pre-treatmentPost-treatmentdPre-treatmentPost-treatmentdFp-value
    AHI# events·h−136.4 (4.9)30.9 (5.0)0.237.5 (4.7)39.5 (4.9)0.10.7586.40.012
    Arousal index# events·h−136.3 (4.2)32.6 (4.3)0.236.9 (4.2)36.6 (4.2)0.00.8442.20.138
    ODI# events·h−127.1 (4.8)24.3 (4.9)0.130.0 (4.8)30.6 (4.8)0.00.9540.10.224
    Respiratory event duration# s22.1 (1.2)22.5 (1.2)0.122.7 (1.2)21.9 (1.2)0.20.4563.60.060
    Total number of awakenings37.7 (4.7)32.7 (4.7)0.235.2 (4.7)35.9 (4.7)0.00.4714.90.029
    Total sleep time min375.2 (20.5)355.4 (21.0)0.2358.4 (20.3)363.8 (20.5)0.10.3052.40.123
    Sleep onset latency min32.5 (9.4)21.2 (9.7)0.229.2 (9.3)23.3 (9.4)0.10.6260.40.550
    Wake after sleep onset min95.7 (13.6)69.7 (13.9)0.582.1 (13.4)77.2 (13.6)0.10.1624.70.031
    Sleep efficiency %74.3 (2.9)79.3 (3.0)0.475.0 (2.9)76.1 (2.9)0.10.7472.50.115
    N1 min84.2 (11.0)76.5 (11.2)0.182.6 (10.8)89.4 (11.0)0.10.8654.70.033
    N2 min180.1 (11.0)164.8 (11.2)0.3163.6 (10.8)164.3 (11.0)0.00.0882.70.102
    N3 min49.1 (11.0)48.3 (11.2)0.054.3 (10.8)49.6 (11.0)0.10.4090.70.421
    REM min62.3 (11.0)63.7 (11.2)0.056.2 (10.8)60.4 (11.0)0.10.2370.20.639
    N1 %22.7 (3.4)21.9 (3.4)0.124.1 (3.3)24.5 (3.4)0.00.5560.50.472
    N2 %48.1 (2.6)47.3 (2.6)0.145.7 (2.6)45.0 (2.6)0.10.1930.00.912
    N3 %13.2 (2.2)13.6 (2.3)0.016.3 (2.3)15.4 (2.3)0.10.0581.10.303
    REM %16.4 (1.6)17.6 (1.6)0.215.8 (1.6)16.7 (1.6)0.10.6130.10.750
    Supine sleep time min160.3 (31.6)156.6 (31.9)0.0170.3 (31.3)175.1 (31.3)0.00.6580.30.571
    Nonsupine sleep time min210.6 (31.6)194.5 (32.0)0.1187.4 (31.3)188.4 (31.4)0.00.3060.90.345
    Supine sleep time %41.8 (8.0)44.0 (8.0)0.147.7 (7.9)50.8 (7.9)0.10.3040.20.701
    Nonsupine sleep time %56.9 (8.0)55.6 (8.1)0.048.2 (7.9)51.7 (7.9)0.10.2840.30.612

    Data are presented as mean (95% confidence interval) unless otherwise stated. CBTi: cognitive behavioural therapy for insomnia; d: Cohen's d for per-group change; AHI: apnoea–hypopnoea index; ODI: oxygen desaturation index. #: collapsed over stage and posture. Bold indicates statistically significant p-values.

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    Cognitive behavioural therapy for insomnia reduces sleep apnoea severity: a randomised controlled trial
    Alexander Sweetman, Leon Lack, R. Doug McEvoy, Nick A. Antic, Simon Smith, Ching Li Chai-Coetzer, James Douglas, Amanda O'Grady, Nicola Dunn, Jan Robinson, Denzil Paul, Danny Eckert, Peter G. Catcheside
    ERJ Open Research Apr 2020, 6 (2) 00161-2020; DOI: 10.1183/23120541.00161-2020

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    Cognitive behavioural therapy for insomnia reduces sleep apnoea severity: a randomised controlled trial
    Alexander Sweetman, Leon Lack, R. Doug McEvoy, Nick A. Antic, Simon Smith, Ching Li Chai-Coetzer, James Douglas, Amanda O'Grady, Nicola Dunn, Jan Robinson, Denzil Paul, Danny Eckert, Peter G. Catcheside
    ERJ Open Research Apr 2020, 6 (2) 00161-2020; DOI: 10.1183/23120541.00161-2020
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