How to Treat Sleep Apnea When You Have Insomnia, Too

OSA and insomnia don’t just happen to occur together — each condition actively makes the other harder to manage, creating a cycle that can be difficult to break.

OSA compounds the problem from the other direction.

Over time, your brain begins to resist sleep. “The brain goes, ‘Sleep is not fun. We don’t like sleep,’” Dr. Hart says.

The result is a self-reinforcing loop: OSA fragments sleep and triggers stress hormones that cause insomnia; insomnia reduces deep sleep, which leaves the airway more vulnerable to collapse, leading to more awakenings and more cortisol.

“The perpetuating factor that keeps insomnia from getting better is often apnea,” Hart says. “Unless we treat the sleep-disordered breathing, nothing we do for insomnia will work for very long.”

Leaving COMISA untreated can have a negative impact on your heart.

The reason relates to how OSA and insomnia each independently affect the heart.

Insomnia, meanwhile, significantly raises average heart rate during sleep — a sign that the nervous system hyperarousal that makes it hard to fall asleep in the first place doesn’t fully switch off once sleep begins. Together, having COMISA keeps the nervous system stuck in “stress mode” overnight, when the body should be recovering.

That said, some people find more success by targeting one issue before tackling the other. The order and pace of treatment is highly individual — what works best depends on the severity of each condition and your own preferences. So, it’s best to discuss your treatment goals with your doctor.

Here are the standard approaches to addressing each condition.

CPAP for Your Sleep Apnea

Ideally, you’ll start CPAP at the same time as you treat your insomnia. But if your sleep apnea is the more urgent concern, for instance you wake up gasping, your doctor may be more aggressive about treating the apnea first, Hart says.

Still, you may see dramatic improvements in sleep by simply addressing OSA. "I've had patients for whom CPAP was a huge game changer in their insomnia,” Hart says. “They started it and within months had made strides."

Regardless of treatment timing, it’s important to give yourself time to adjust to CPAP therapy. For patients who struggle with discomfort with a CPAP mask, Katherine Belon, PhD, a licensed clinical psychologist with certifications in behavioral sleep medicine and cognitive behavioral therapy for insomnia with a private practice in Albuquerque, New Mexico, recommends wearing it for 20 to 30 minutes a day while watching TV or relaxing. Once you feel more comfortable, you can start incorporating your CPAP into your nightly routine.

CBTi for Your Insomnia

• Stimulus Control This trains your brain to associate your bed with sleep rather than wakefulness or anxiety. If you’re lying awake for more than 15 to 20 minutes, your therapist will encourage you to get up. “I also like to send a message that anytime you’re experiencing really strong negative emotions in bed — feeling frustrated, anxious, or panicky — that is also a cue to get out of bed,” Belon says.
• Sleep Restriction This limits the amount of time you spend in bed to try to make you sleepier. “Your sleep drive is similar to hunger — it builds up the longer you go without sleep,” Belon explains. “If you take a nap, it’s like having a snack right before dinner. It’s going to weaken that appetite or sleep drive.” Your therapist will set a specific bedtime and wake time, often pushing your bedtime later than usual to strengthen that drive before gradually adjusting the window as your sleep improves.
• Sleep Education Your therapist will address common myths and misconceptions about sleep, such as the popular advice to do something boring when you can’t sleep. That approach usually backfires, as it leaves your mind free to worry about sleep, Belon says. “You’re better off doing something that takes your mind off the fact that you can’t sleep, and waiting until you feel nice and sleepy as your cue to get back into bed.”
• Cognitive Therapy This component targets the anxious thoughts and beliefs about sleep that develop over time and keep insomnia going. “Decreasing anxiety around insomnia is the biggest goal,” Belon says.

It typically takes four to eight sessions for CBTi to address insomnia. But people with COMISA may need more time, Belon says.

• COMISA is comorbid insomnia and sleep apnea, a condition that affects an estimated 18 and 42 percent of people worldwide.
• When they happen together, insomnia and obstructive sleep apnea make each harder to manage, worsening the potential for heart-related complications.
• Healthcare providers typically recommend treating insomnia and OSA simultaneously with a combination of cognitive behavioral therapy for insomnia and continuous positive airway pressure.