title: Refractory insomnia and sleep-disordered breathing: a pilot study.
abstract: OBJECTIVE
  To assess an uncontrolled, open-label trial of sleep-disordered breathing (SDB) treatment on two different samples of chronic insomnia patients.
  
  
  METHODS
  In Study 1 (Retrospective), data from one diagnostic and one continuous positive airway pressure (CPAP) titration polysomnogram were compiled from 19 chronic insomnia patients with SDB. Objective polysomnogram indicators of sleep and arousal activity and self-reported sleep quality were measured. In Study 2 (Prospective), clinical outcomes were assessed after sequential cognitive-behavioral therapy (CBT) and SDB therapy (CPAP, oral appliances, or bilateral turbinectomy) were provided to 17 chronic insomnia patients with SDB. Repeat measures included the Insomnia Severity Index, Functional Outcomes of Sleep Questionnaire, Pittsburgh Sleep Quality Index, and self-reported insomnia indices and CPAP use.
  
  
  RESULTS
  In Study 1, seven objective measures of sleep and arousal demonstrated or approached significant improvement during one night of CPAP titration. Sixteen of 19 patients reported improvement in sleep quality. In Study 2, Insomnia Severity Index, Functional Outcomes of Sleep Questionnaire, and Pittsburgh Sleep Quality Index improved markedly with CBT followed by SDB treatment and achieved an average outcome equivalent to curative status. Improvements were large for each treatment phase; however, of 17 patients, only 8 attained a nonclinical level of insomnia after CBT compared with 15 patients after SDB therapy was added. Self-reported insomnia indices also improved markedly, and self-reported SDB therapy compliance was high.
  
  
  CONCLUSIONS
  In one small sample of chronic insomnia patients with SDB, objective measures of insomnia, arousal, and sleep improved during one night of CPAP titration. In a second small sample, validated measures of insomnia, sleep quality, and sleep impairment demonstrated clinical cures or near-cures after combined CBT and SDB therapies. These pilot results suggest a potential value in researching the pathophysiological relationships between SDB and chronic insomnia, which may be particularly relevant to patients with refractory insomnia.
authors.affiliation: Sleep and Human Health Institute, Albuquerque, New Mexico 87109, USA. bkrakow@sleeptreatment.com
authors.forename: Barry
authors.initials: B
authors.lastname: Krakow
authors.forename: Dominic
authors.initials: D
authors.lastname: Melendrez
authors.forename: Samuel A
authors.initials: SA
authors.lastname: Lee
authors.forename: Teddy D
authors.initials: TD
authors.lastname: Warner
authors.forename: Jimmy O
authors.initials: JO
authors.lastname: Clark
authors.forename: David
authors.initials: D
authors.lastname: Sklar
mesh_terms: D002908:Chronic Disease; D015928:Cognitive Behavioral Therapy / Q000379:methods; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010865:Pilot Projects; D017286:Polysomnography; D011175:Positive-Pressure Respiration / Q000379:methods; D011594:Psychometrics; D012189:Retrospective Studies; D012720:Severity of Illness Index; D012891:Sleep Apnea Syndromes / Q000175:diagnosis / Q000453:epidemiology*; D007319:Sleep Initiation and Maintenance Disorders / Q000175:diagnosis / Q000453:epidemiology*; D012894:Sleep Stages; D012895:Sleep, REM / Q000502:physiology