Using CPAP and CBT‑I together can lead to better results than using either treatment on its own. CPAP focuses on fixing the physical cause of sleep disruptions by keeping the airway open. CBT‑I, on the other hand, helps change the thoughts and habits that interfere with falling or staying asleep. 

When someone has both insomnia and obstructive sleep apnea, treating only one issue often doesn’t work. Both problems need to be addressed at the same time for sleep to truly improve.

Why Is It Hard to Treat Insomnia and Sleep Apnea Together?

Treating insomnia and sleep apnea at the same time is difficult because they come from very different causes. Both can lead to poor sleep, daytime tiredness, and serious health problems. But sleep apnea is caused by a physical issue, when the airway collapses during sleep, it blocks airflow and forces the brain to wake up. Insomnia, on the other hand, is a state of hyperarousal caused by both mental and physical factors that keeps the brain too alert for restful sleep.. It happens when the brain stays too alert, making it hard to relax, fall asleep, or stay asleep.

When both problems occur together, called COMISA (Comorbid Insomnia and Sleep Apnea), one treatment alone usually doesn’t work. CPAP may fix the breathing issue, but someone can still lie awake for hours with insomnia. And, in fact, though CPAP helps with sleep apnea, it can worsen the insomnia condition because the equipment, sounds, and air flow can be distracting for insomnia sufferers. This can lead people to skip CPAP use altogether. Ignoring the insomnia side leads to poor results, no matter how well the machine works. Around half of the people with sleep apnea also have chronic insomnia symptoms. However, not all receive care for both. This gap leaves many patients stuck, tired, frustrated, and without real relief.

What Does CBT‑I Actually Do?

CBT‑I (Cognitive Behavioral Therapy for Insomnia) is a short-term, structured therapy. It focuses on correcting unhelpful sleep-related thoughts and behaviors. Instead of targeting breathing, it helps retrain the brain to sleep more effectively.

Here’s how it works:

  • Stimulus control breaks the mental link between the bed and frustration. Patients learn to only use the bed for sleep, leaving it during long periods of wakefulness to avoid reinforcing insomnia.
  • Sleep restriction temporarily limits time in bed to build “sleep drive,” helping consolidate fragmented sleep into deeper, more restorative rest.
  • Cognitive therapy challenges irrational beliefs like “If I don’t fall asleep now, I’ll ruin tomorrow,” which fuel nighttime anxiety.
  • Relaxation strategies such as diaphragmatic breathing, progressive muscle relaxation, or guided imagery calm the mind and body.
  • Sleep hygiene reinforces habits that support rest, such as consistent wake times, reduced caffeine, and screen-time limits.

Studies show that up to 80% of people who complete CBT‑I experience lasting improvement. These benefits often continue long after treatment ends. It’s the gold standard for chronic insomnia.

How Does Insomnia Affect CPAP Adherence?

Insomnia makes it much harder to stick with CPAP. Many people give up on the machine because they expect it to help them fall asleep, but CPAP doesn’t do that. It improves breathing by keeping your airway open, but it doesn’t calm your thoughts or help your brain relax. If someone already struggles with racing thoughts or long stretches of being awake, adding a mask to the mix can feel overwhelming. It’s common for patients to feel anxious, restless, or even panicked while using it.

When sleep doesn’t improve right away, frustration builds. Some people start avoiding the machine altogether or only use it for part of the night. Insomnia can also create a kind of “sleep anxiety,” where bedtime feels stressful and discouraging. This makes it harder to even begin the CPAP routine each night, let alone use it consistently. That’s why untreated insomnia is one of the top reasons people abandon CPAP therapy.

Combining CBT‑I with CPAP

Treatment outcomes improve across the board. Several randomized controlled trials confirm that combining CBT-I with CPAP leads to:

  • Greater insomnia remission rates
  • Longer CPAP usage times
  • Higher treatment acceptance
  • Better daytime functioning
  • Less fatigue and more alertness during the day

CBT‑I Before or During CPAP

In a trial with 118 adults, participants were randomized into three groups: CBT-I before CPAP, CBT-I during CPAP, or CPAP alone. Both CBT-I groups saw significantly improved fatigue scores, better quality of life, and greater improvements in daytime function (measured by the Functional Outcomes of Sleep Questionnaire and Flinders Fatigue Scale). CPAP alone showed smaller gains (1).

The MATRICS Trial

This trial found that patients receiving both CBT-I and CPAP had a much greater reduction in insomnia severity. They were also more likely to reach “good sleeper” status and achieve full insomnia remission. While PAP adherence itself didn’t change, subjective sleep quality did (2).

CBT-I Increases CPAP Use

Another study showed that CBT-I increased average nightly CPAP usage by 61 minutes compared to usual care. Patients also had higher initial acceptance and fewer dysfunctional beliefs about sleep, meaning they were more willing to stick with treatment (3).

The conclusion is clear. CBT-I makes CPAP easier to tolerate, more effective, and more sustainable, especially in patients with COMISA.

How to Get Started If You Think You Have COMISA

If you suspect you have both sleep apnea and insomnia, the first step is clarity. Proper diagnosis is essential.

Here’s how to begin:

  • Get a sleep study. Whether it’s an in-lab polysomnogram or a home sleep apnea test, this will confirm whether you have OSA and how severe it is. If your apnea-hypopnea index (AHI) is 5 or higher, treatment is typically recommended.
  • Don’t ignore insomnia symptoms. Trouble falling asleep, waking up multiple times a night, or waking too early, especially if it happens at least 3 nights a week for 3+ months, points to chronic insomnia.
  • Ask your provider about CBT‑I. If your insomnia was present before you started CPAP, or if it hasn’t improved despite CPAP use, CBT‑I may be the missing piece. You don’t have to “fail” CPAP first.
  • Choose a clinic that treats both. Ideally, you want a provider trained in both sleep-disordered breathing and behavioral sleep medicine. Integrated care leads to better outcomes.

Make sure to track your symptoms, sleep diary apps, CPAP usage data, and even mood or energy logs can help your doctor tailor treatment. Patients who advocate for themselves get better care.

Combining CPAP with CBT‑I

Sleep Better with The Insomnia and Sleep Institute of Arizona

The Insomnia and Sleep Institute of Arizona helps you reclaim deep, lasting rest. We treat the full picture, including both sleep apnea and the insomnia that often hides beneath it.

Our board-certified sleep doctors understand COMISA and provide complete care using both CPAP and CBT‑I. Every part of your treatment is adjusted to fit how you sleep, think, and feel. From pressure settings to nighttime habits, we focus on what works for you.

What you can expect:

  • Every sleep apnea evaluation includes a full insomnia screening
  • CBT‑I sessions are led by clinicians certified in behavioral sleep medicine
  • We help patients overcome CPAP struggles by solving the real barriers, not by pushing harder
  • We work with your insurance to make treatment accessible and stress-free

If you’re still waking up tired, there may be more going on than just sleep apnea. And there is a proven way to fix it.

We welcome patients at our Gilbert, Scottsdale, and Phoenix locations. Contact us today and start taking back your nights.

References

  1. Tu, A. Y., Crawford, M. R., Dawson, S. C., Fogg, L. F., Turner, A. D., Wyatt, J. K., Crisostomo, M. I., Chhangani, B. S., Kushida, C. A., Edinger, J. D., Abbott, S. M., Malkani, R. G., Attarian, H. P., Zee, P. C., & Ong, J. C. (2020). 0655 CBT-I and CPAP in Comorbid Insomnia and Sleep Apnea: Effects on Daytime Functioning. Sleep, 43(Supplement_1), A250–A250. https://doi.org/10.1093/sleep/zsaa056.651
  2. Ong, J. C., Crawford, M. R., Dawson, S. C., Fogg, L. F., Turner, A. D., Wyatt, J. K., Crisostomo, M. I., Chhangani, B. S., Kushida, C. A., Edinger, J. D., Abbott, S. M., Malkani, R. G., Attarian, H. P., & Zee, P. C. (2020). A randomized controlled trial of CBT-I and PAP for obstructive sleep apnea and comorbid insomnia: main outcomes from the MATRICS study. SLEEP, 43(9). https://doi.org/10.1093/sleep/zsaa041
  3. ‌Sweetman, A., Lack, L., Catcheside, P. G., Antic, N. A., Smith, S., Chai-Coetzer, C. L., Douglas, J., O’grady, A., Dunn, N., Robinson, J., Paul, D., Williamson, P., & McEvoy, R. D. (2019). 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, 42(12). https://doi.org/10.1093/sleep/zsz178

Disclaimer: The information provided in this blog post is for educational and informational purposes only and is not intended as a substitute for professional medical advice, diagnosis, or treatment. Always consult with a licensed healthcare provider for recommendations specific to your individual health needs.