COMISA: How to Manage Insomnia and Sleep Apnea Together

Imagine lying awake at night, your mind racing, while your breathing keeps stopping and starting. You’re not alone. About 45% of people diagnosed with sleep apnea also struggle with chronic insomnia. This isn’t just bad luck-it’s a real, recognized condition called COMISA: Comorbid Insomnia and Sleep Apnea. And treating one without the other? That’s like trying to fix a leaky roof while ignoring the mold growing underneath.

What Is COMISA, Really?

COMISA isn’t just having two sleep problems at once. It’s when insomnia and obstructive sleep apnea (OSA) feed off each other. You might fall asleep fine, but then wake up 10 times an hour because your airway collapses. Or you might sleep through the night but wake up at 3 a.m. and can’t get back to sleep-even with your CPAP on. That’s COMISA.

This isn’t rare. Research from Flinders University in Australia shows that between 39% and 58% of people with sleep apnea also have clinical insomnia. That’s nearly half of all OSA patients. Yet, most doctors still treat them as separate problems. One treats the breathing with a CPAP machine. The other prescribes sleep meds for insomnia. Neither fixes the real issue: the two conditions are tangled together.

Why CPAP Alone Fails in COMISA

CPAP is the gold standard for sleep apnea. When used correctly, it works 85-90% of the time. But in COMISA patients, adherence drops to just 42.7%. Why? Because CPAP can make insomnia worse.

The mask feels claustrophobic. The air pressure wakes you up. The hose tangles. You start associating your bed with frustration, not sleep. A 2022 survey of over 1,200 COMISA patients found that 68% stopped using CPAP within six months-unless they got help for their insomnia at the same time.

Even when people stick with CPAP, their insomnia often doesn’t improve. The Sleep Heart Health Study showed that 39% of OSA patients still had trouble sleeping after months of CPAP use. That’s because CPAP fixes breathing, but not the mental habits that keep you awake.

Why CBT-I Alone Isn’t Enough

Cognitive Behavioral Therapy for Insomnia (CBT-I) is the most effective treatment for insomnia, helping 70-80% of people. It teaches you to break the cycle of worrying about sleep, reduce time in bed when you’re not sleeping, and retrain your brain to associate bed with rest.

But if you have sleep apnea, CBT-I alone won’t fix the breathing pauses that keep waking you up. You might learn to sleep better-but if your oxygen levels drop every 45 seconds, your body will still be in survival mode. Your brain won’t let you reach deep, restorative sleep. And without fixing the apnea, you’re still at risk for high blood pressure, heart attacks, and stroke.

The Only Proven Solution: Do Both at Once

The breakthrough came when researchers stopped treating these conditions one after the other-and started treating them together.

Dr. Alexander Sweetman’s team at Flinders University ran multiple trials showing that combining CBT-I with CPAP from day one leads to dramatically better results. In one study, 63% of COMISA patients saw their insomnia go into remission after 12 weeks of combined treatment. With CPAP alone? Only 29% improved.

And it’s not just about sleep quality. CPAP usage jumped by an average of 1.2 hours per night when paired with CBT-I. That’s not a small gain-it’s the difference between barely surviving the night and actually feeling rested in the morning.

The secret? CBT-I helps patients tolerate CPAP. It teaches them to stop fighting the machine, to relax into it, and to reframe the discomfort as part of healing-not punishment. One patient on a sleep forum described it this way: “I used to hate my CPAP. After CBT-I, I started looking forward to putting it on. It felt like a tool, not a cage.”

What Does Combined Treatment Look Like?

It’s not complicated, but it does require coordination. Here’s how it works in practice:

1. Diagnosis: You need a sleep study (polysomnography) to confirm OSA (AHI ≥5) and an Insomnia Severity Index (ISI) score of 15 or higher to confirm clinical insomnia.
2. Start CPAP and CBT-I together: No waiting. No “try CPAP first.” You begin both treatments on the same day.
3. Modify CBT-I for CPAP users: Standard CBT-I doesn’t account for mask discomfort or pressure-related awakenings. Specialized protocols address these directly-like using stimulus control to rebuild positive associations with bed, even with the machine on.
4. Use a sleep coach: Trained professionals guide you through both treatments. They help you adjust pressure settings, troubleshoot mask leaks, and reframe anxious thoughts about sleep.

A 2020 trial showed that patients who got five sessions of combined CBT-I and CPAP coaching improved their insomnia by 54% and added over an hour of CPAP use per night-six months later.

What About Digital CBT-I?

Apps like Sleepio and Somryst now offer digital CBT-I programs. Some even integrate with CPAP data to personalize advice. These are great for mild cases or people in rural areas with no sleep specialists nearby.

But they’re not for everyone. A 2023 study in JAMA Network Open found that digital CBT-I worked well for COMISA patients with mild OSA (AHI 5-15)-65% saw remission. But for moderate to severe OSA (AHI >15), success dropped to 38%. Why? Because the physical disruption from apnea is too strong to fix with an app alone.

That’s why the best results still come from working with a trained psychologist who understands both insomnia and sleep apnea. If you’re struggling with severe breathing issues, don’t rely on an app. Get human support.

Other Treatments? Orexin Antagonists, Mandibular Devices, Neurostimulation

There are other options-but they’re not first-line.

Orexin antagonists like suvorexant (recently FDA-approved for COMISA in December 2023) help you stay asleep by blocking brain signals that keep you awake. In trials, they improved sleep maintenance in 57% of COMISA patients when used with CPAP. But they’re expensive, can cause next-day drowsiness, and aren’t recommended for long-term use.

Mandibular advancement devices (mouthpieces) work for mild to moderate OSA, but they don’t help with insomnia. They’re not a substitute for CPAP in moderate-severe cases.

Neurostimulation (like hypoglossal nerve stimulation) is an implantable device for severe OSA patients who can’t tolerate CPAP. But it doesn’t address insomnia at all. And it’s invasive, expensive, and only for a small subset.

Right now, the only treatment with strong, repeated evidence for COMISA is CBT-I + CPAP. Everything else is a backup plan.

Why Don’t More Doctors Treat COMISA This Way?

Because most don’t know how.

A 2022 survey of U.S. sleep centers found that only 28% had formal referral pathways between sleep physicians and behavioral sleep specialists. Most patients get referred to one specialist, then the other-months apart. The average wait time to see a CBT-I-trained psychologist? 14.3 weeks.

Even when doctors know about COMISA, they often don’t have the resources. CBT-I requires 40-60 hours of specialized training. Few psychologists have it. Few sleep labs coordinate with them.

But things are changing. In January 2024, Medicare introduced new billing codes (G2212-G2214) specifically for integrated COMISA treatment. That means clinics can now get paid for doing it right.

Insurance companies are noticing the savings too. UnitedHealthcare found that COMISA patients on combined treatment used 22% less healthcare overall-saving $1,843 per person per year. That’s not just better sleep. That’s fewer ER visits, fewer heart problems, fewer missed workdays.

What If You’re Already on CPAP and Still Can’t Sleep?

If you’ve been using CPAP for months and still wake up at 3 a.m. every night, you might have COMISA. Here’s what to do next:

• Take the Insomnia Severity Index (ISI) test online-it’s free and takes 2 minutes.
• If your score is 15 or higher, ask your sleep doctor for a referral to a psychologist trained in CBT-I.
• Don’t wait. The longer you go without treating both, the harder it gets to break the cycle.
• Track your CPAP usage. If you’re using it less than 4 hours a night, you’re not getting the benefit-and your insomnia is likely making it worse.

One patient, a 58-year-old teacher from Hobart, told me: “I was on CPAP for two years. I still felt exhausted. I thought I was broken. Then I got CBT-I. Now I sleep 7 hours. I don’t even notice the machine anymore.”

The Bigger Picture: COMISA Is the Future of Sleep Medicine

Sleep medicine is moving away from siloed care. COMISA is a model for how we treat other overlapping conditions-like depression and chronic pain, or anxiety and IBS.

By 2027, nearly 40% of U.S. sleep centers plan to offer integrated COMISA programs. The American Academy of Sleep Medicine now officially recommends it. And with new AI tools predicting who will respond best to combined therapy, we’re getting closer to truly personalized sleep care.

But right now, the biggest barrier isn’t science. It’s access. Only 1% of people with insomnia ever get CBT-I. And only 18% of COMISA patients get treated with both therapies.

If you’re one of them, you don’t need to wait. Ask for help. Demand coordination. Push for both treatments together. Because sleep isn’t just about breathing-or just about falling asleep. It’s about both. And you deserve to get both right.

What’s Next? Don’t Wait for the System to Catch Up

You don’t need to wait for your doctor to know about COMISA. You don’t need to wait for insurance to cover everything. You just need to ask for both treatments-CBT-I and CPAP-together.

Keep a sleep diary. Track your CPAP usage. Score your insomnia with the ISI. Bring it to your next appointment. Say: “I think I have COMISA. I want to try CBT-I and CPAP at the same time.”

This isn’t just about sleep. It’s about your heart, your mood, your energy, your life. And you deserve to feel rested-not just surviving the night, but truly waking up.