COMISA: How to Manage Insomnia and Sleep Apnea Together

Dec, 16 2025

Imagine lying awake at 3 a.m., heart pounding, air mask tight on your face, wondering why you’re still tired even though you’re using your CPAP machine every night. You’ve been told you have sleep apnea - but the insomnia won’t leave. This isn’t just bad luck. It’s COMISA - Comorbid Insomnia and Sleep Apnea - and it’s far more common than most doctors realize.

What Exactly Is COMISA?

COMISA isn’t just having two sleep problems at once. It’s when insomnia and obstructive sleep apnea (OSA) feed off each other, making both worse. You might fall asleep easily but wake up 10 times a night because your airway collapses. Or you might lie there for hours, too anxious to sleep, while your body struggles to breathe. The result? Exhaustion that doesn’t go away, no matter how long you stay in bed.

Research from Flinders University in Australia shows that between 39% and 58% of people diagnosed with sleep apnea also have clinical insomnia. That’s nearly half of all OSA patients. Yet, most clinics still treat them as separate issues - first fix the breathing, then deal with the sleeplessness. That approach often fails.

Why Standard Treatments Fall Short

CPAP therapy 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 the mask itself can trigger or worsen insomnia. The pressure, the noise, the feeling of being trapped - all of it makes it harder to fall asleep. One patient on Reddit put it simply: “The machine that’s supposed to help me sleep is the reason I can’t.”

On the flip side, cognitive behavioral therapy for insomnia (CBT-I) is highly effective for pure insomnia, helping 70-80% of people. But if you’re still having breathing pauses every night, no amount of sleep hygiene or stimulus control will fix the root problem. You’ll still wake up gasping, your brain still in survival mode.

Treating one condition without the other is like trying to fix a car with a broken engine by just changing the tires. It might look better, but it won’t go anywhere.

The Proven Solution: CBT-I + CPAP Together

The breakthrough came when researchers stopped treating these as separate problems and started treating them as one. Dr. Alexander Sweetman’s work at Flinders University showed that combining CBT-I with CPAP from day one leads to dramatically better outcomes.

In a major clinical trial, patients who got both treatments saw a 63% reduction in insomnia symptoms after 12 weeks. Those who only got CPAP? Only 29% improved. Even more striking: CPAP usage increased by an average of 1.2 hours per night when CBT-I was added. That’s not a small gain - it’s the difference between barely surviving the night and actually sleeping.

CBT-I doesn’t just help you sleep better. It helps you tolerate CPAP better. Techniques like sleep restriction (limiting time in bed to match actual sleep time) train your brain to associate the bed with sleep, not frustration. Stimulus control teaches you to get out of bed if you’re not sleeping - which reduces the anxiety of lying there with a mask on. And relaxation training lowers the stress response that keeps your body tense, even when your airway is open.

Who Needs This Approach?

Not everyone with sleep apnea has COMISA. But if you’ve been on CPAP for more than a few weeks and still feel exhausted, have trouble falling asleep, or wake up frequently without knowing why, you might have it.

Diagnostic criteria are clear: you need a sleep study (polysomnography) showing an Apnea-Hypopnea Index (AHI) of 5 or higher, plus an Insomnia Severity Index (ISI) score of 15 or above. That’s not just “I had a rough night.” That’s insomnia severe enough to impact your mood, focus, and daily life.

The type of insomnia matters too. About 68% of COMISA patients struggle with sleep maintenance - waking up and not being able to fall back asleep. That’s different from sleep onset insomnia (trouble falling asleep at the start of the night), which makes up the other 32%. CBT-I protocols can be adjusted for each type, making treatment more precise.

Split scene showing frustration with CPAP on one side and peaceful sleep with combined therapy on the other.

What If You Can’t Get CBT-I?

Access is still a major barrier. Only 12% of patients report having access to a psychologist trained in CBT-I for COMISA. Wait times can stretch to 14 weeks. But there are options.

Digital CBT-I platforms like Sleepio and Somryst now offer COMISA-specific modules. These are not generic apps - they’re designed to integrate CPAP usage data and adjust therapy based on your nightly breathing patterns. A 2023 study in JAMA Network Open found these platforms helped 65% of mild COMISA cases (AHI 5-15) achieve insomnia remission. For moderate to severe cases (AHI >15), the success rate drops to 38%, so they’re not a full replacement - but they’re a bridge.

Some patients benefit from gradual CPAP adaptation. Instead of starting at full pressure, devices like ResMed’s AirSense 11 allow for ramping - slowly increasing pressure over 20-45 minutes. Combine that with a consistent bedtime routine and avoiding screens before bed, and many see big improvements.

What About Medications or Other Devices?

Medications like suvorexant, an orexin antagonist approved by the FDA in December 2023 for COMISA, show promise. In trials, it improved sleep maintenance by 42% when paired with CPAP. But it’s not a first-line treatment. It’s expensive, can cause next-day drowsiness, and doesn’t fix the underlying behavioral patterns that keep insomnia going.

Mandibular advancement devices work for mild to moderate OSA, but they don’t help with insomnia. Neurostimulation devices are still experimental. The bottom line: nothing else comes close to the evidence behind combined CBT-I and CPAP.

Why Most Doctors Still Miss This

Primary care doctors, sleep labs, and even some sleep specialists still treat these conditions in silos. A patient with loud snoring gets a CPAP referral. A patient with trouble sleeping gets a referral to a therapist. Few are trained to look for both.

A 2022 survey of U.S. sleep centers found that 63% had no formal system to refer OSA patients to behavioral sleep specialists. Only 28% had any kind of coordinated care pathway. That’s why the average COMISA patient waits 7.2 years to get the right diagnosis.

The American Academy of Sleep Medicine updated its guidelines in 2023 to explicitly recommend combined treatment. But guidelines don’t change practice overnight. It takes training, funding, and coordination - things most clinics still lack.

A home sleep monitor projecting calming digital therapy glyphs above a sleeping person with glowing health data.

What’s Changing - and What’s Next

Things are moving. In January 2024, Medicare added new billing codes (G2212-G2214) specifically for integrated COMISA treatment. That means clinics can now get paid for bringing together sleep physicians and psychologists. UnitedHealthcare reported $1,843 in annual savings per patient when COMISA was treated properly - because fewer ER visits, fewer missed workdays, fewer depression diagnoses.

Researchers are now using AI to predict who’s at risk for COMISA before it becomes severe. A 2023 model developed by Sweetman’s team can predict COMISA with 78% accuracy using just sleep logs, symptom reports, and basic health data.

Home-based diagnostic tools that test for both breathing disruptions and sleep fragmentation are in development. Soon, you might be able to get a full COMISA diagnosis from a single overnight test at home.

What You Can Do Right Now

If you suspect you have COMISA:

Track your sleep for two weeks - note when you fall asleep, wake up, and how rested you feel.
Use your CPAP consistently for at least 4 hours a night. Don’t quit because of discomfort - it gets better.
Ask your sleep doctor for an Insomnia Severity Index (ISI) test. If your score is 15 or higher, ask about CBT-I.
If you can’t see a specialist, try a digital CBT-I program that’s designed for COMISA (look for one that integrates with your CPAP data).
Don’t accept “just live with it.” Your fatigue isn’t normal. Your sleep isn’t broken beyond repair.

Final Thought: You’re Not Alone

You’re not failing because you can’t sleep with a mask on. You’re not weak because you’re still tired after months of treatment. You have a complex, under-recognized condition that requires a smarter approach - not more willpower.

The science is clear: treating insomnia and sleep apnea together works. The systems are slowly catching up. And you? You’re already ahead of the curve just by asking the right questions.

Is COMISA the same as having insomnia and sleep apnea separately?

No. COMISA is a specific clinical syndrome where insomnia and obstructive sleep apnea interact in a way that makes both worse. Treating them separately often fails because the symptoms feed into each other - for example, CPAP discomfort can worsen insomnia, and chronic sleeplessness can increase airway collapse during sleep. COMISA requires a combined treatment approach.

Can I treat COMISA with just a CPAP machine?

CPAP alone treats the breathing issues but doesn’t fix insomnia. In fact, up to 39% of OSA patients on CPAP still report persistent insomnia. Without addressing the sleep maintenance or sleep onset problems, CPAP adherence drops significantly. Combined treatment with CBT-I improves both sleep quality and CPAP usage.

What is CBT-I, and how does it help with sleep apnea?

Cognitive Behavioral Therapy for Insomnia (CBT-I) is a structured program that changes thoughts and behaviors around sleep. It doesn’t directly fix breathing pauses, but it reduces the anxiety and hyperarousal that make you wake up from them. It also improves your tolerance for CPAP by teaching you to associate your bed with rest, not frustration. Studies show CBT-I can reduce OSA severity by up to 15% by consolidating sleep and reducing nighttime awakenings.

How do I know if I have COMISA?

You need two things: a sleep study showing an AHI of 5 or higher (indicating sleep apnea), and a score of 15 or higher on the Insomnia Severity Index (ISI). If you’ve been on CPAP for weeks and still can’t fall or stay asleep, or if you were diagnosed with insomnia but snore loudly or wake up gasping, you may have COMISA. Ask your doctor for both tests.

Are digital CBT-I apps effective for COMISA?

Yes - but with limits. Digital CBT-I platforms like Sleepio and Somryst work well for mild COMISA (AHI 5-15), helping 65% of users achieve insomnia remission. For moderate to severe OSA (AHI >15), success drops to 38%. These apps are best used as a bridge to in-person care or when specialists aren’t available. Look for platforms that sync with your CPAP device for better results.

Why is it taking so long for doctors to treat COMISA properly?

Most sleep clinics are set up to treat one condition at a time. There’s little coordination between sleep labs and behavioral health providers. Only 28% of U.S. sleep centers have formal referral pathways for COMISA. Training, funding, and insurance reimbursement have lagged behind the science - but that’s changing. New Medicare codes introduced in 2024 now pay for integrated care, which should speed up adoption.

What’s the biggest mistake people make with COMISA?

Giving up on CPAP because of insomnia - or waiting to treat insomnia until after CPAP “works.” Neither approach works. The longer you delay combining treatments, the more your brain learns to associate the bed with frustration. The sooner you start both CBT-I and CPAP together, the faster you’ll get real, lasting sleep.

15 Comments

Donna Packard
December 18, 2025 AT 03:24

I was diagnosed with OSA last year and struggled with the mask for months. I almost gave up until my sleep doc suggested CBT-I alongside CPAP. It wasn't magic, but slowly, the anxiety around bedtime faded. I'm now sleeping 6+ hours most nights. It took time, but combining both felt like finally getting the full picture.
Chris Van Horn
December 19, 2025 AT 11:57

This is exactly why I stopped trusting American medicine. You're telling me they didn't know this was a thing until 2023? We've had the data for a decade. The system is broken. CBT-I should be standard, not an afterthought. And don't get me started on how long it takes to get a referral.
Raven C
December 21, 2025 AT 10:42

The notion that COMISA is merely a comorbidity is, frankly, reductive. One must consider the neurophysiological entanglement: the hyperarousal state induced by chronic sleep fragmentation directly exacerbates upper-airway collapsibility via sympathetic overdrive. The paradigm shift toward integrated intervention is not merely clinical-it is epistemological.
Naomi Lopez
December 22, 2025 AT 08:31

I appreciate the article, but it's missing one crucial point: the role of circadian misalignment in COMISA. Many patients have delayed sleep phase disorder too. CBT-I protocols need to account for chronotype. Otherwise, you're treating symptoms, not the root.
Sachin Bhorde
December 23, 2025 AT 18:30

I work in sleep tech in Bangalore. We see this all the time. CPAP alone? Nope. CBT-I + CPAP? Game changer. But access? In India, it's nearly impossible. Digital CBT-I apps are the only lifeline for most. The ones that sync with CPAP data? Life-saving. Try Somryst. It's not perfect, but it's something.
Salome Perez
December 24, 2025 AT 19:58

As a behavioral sleep specialist, I've seen patients transform when we treat both conditions together. One woman, 62, had been on CPAP for 4 years and still woke up 8 times a night. After 8 weeks of CBT-I-sleep restriction, stimulus control, relaxation-she went from 3 hours of sleep to 6.5. And she started using her CPAP 7 nights a week. The mind and body are connected. We need to treat them as one.
Marie Mee
December 25, 2025 AT 02:26

They're hiding something. Why did the FDA approve suvorexant for COMISA but not push CBT-I harder? Big Pharma owns the sleep industry. They make more money selling pills than training therapists. That's why your doctor won't mention CBT-I unless you ask. Watch the money trail.
Kaylee Esdale
December 25, 2025 AT 16:27

I used to hate my CPAP. Felt like a robot. Then I tried a digital CBT-I app that told me to get out of bed if I wasn't asleep in 20 mins. I did it. And guess what? I stopped dreading bedtime. Now I sleep better than I have in 10 years. You don't need a therapist. You just need to stop fighting your brain.
Joe Bartlett
December 25, 2025 AT 18:08

Blimey, this is why the UK NHS is so behind. We treat apnea, then if you're still tired, we say 'try harder'. No one mentions insomnia. I had to Google COMISA myself. Shameful. We need this integrated care here too.
Jody Patrick
December 27, 2025 AT 16:44

America's healthcare system is a joke. We pay for machines, not therapists. This article is just another $$$ scheme. CBT-I costs nothing but time. Why aren't they pushing that?
Radhika M
December 28, 2025 AT 18:08

I'm a nurse in Mumbai. We have zero access to CBT-I. But I tell my patients: don't use your CPAP in bed. Use it on the couch first. Get used to the noise. Then try the bed. Small steps. It works.
Meghan O'Shaughnessy
December 29, 2025 AT 22:05

I had COMISA for 8 years. Tried everything. The moment I started CBT-I with my CPAP? My AHI dropped from 22 to 8. Not because my airway changed. Because I stopped panicking when I woke up. My brain finally stopped screaming 'DANGER'.
Michael Whitaker
December 30, 2025 AT 09:02

I must respectfully disagree with the assertion that CBT-I improves CPAP adherence. In my clinical experience, the psychological burden of the mask remains unchanged. CBT-I may mitigate distress, but it does not alter the physical discomfort. One must still confront the reality of the device.
Patrick A. Ck. Trip
January 1, 2026 AT 04:04

i just wanted to say thank you for this post. i've been on cpap for 2 years and still couldn't sleep. i thought i was broken. then i found out about comisa. i started a digital cbt-i program last month. i'm not cured. but i'm sleeping. and that's more than i've had in a decade. you're not alone. it's not your fault. keep going.
Virginia Seitz
January 2, 2026 AT 05:18

I'm finally sleeping 😭❤️