Cognitive-Behavioral Therapy in Continuous Positive Air Pressure Adherence for Obstructive Sleep Apnea: A Follow-up Study


1 PhD student of psychology, Department of Psychology, Faculty of Humanities, Tarbiat Modares University, Tehran, Iran

2 Associated professor, Tarbiyat Modares University, Tehran, Iran


AbstractIntroduction: Sleep apnea disorder brings about negative effects to the quality of life of the people involved. Debilitation of cognitive functioning is one of the consequences of this condition. However, scant researches have been carried out to explore the efficacy of cognitive therapy in mitigating the clinical symptoms and cognitive functions of the brain. By combining the cognitive method and medical treatment, this research aims at comparing the effectiveness of Continuous Positive Air Pressure (CPAP) therapy and Cognitive-Behavioral Treatment (CBT) in improving mental cognitive functions among patients with sleep apnea disorder.Methods: The study population included all patients who referred to the sleep disorders clinic in Tehran. Our sample consisted of 45 subjects who were randomly allocated into three groups of 15 individuals (CPAP, combined treatment, and control). All three groups were psychologically assessed prior to the intervention. Next, individuals in the cognitive-behavioral group underwent CPAP and 12 sessions of cognitive training, progressive muscle relaxation, mental visualization, and sleep hygiene. The other group went through CPAP therapy and the third group was also assessed. After the intervention, all groups were again psychologically assessed. Data collection instruments included Wisconsin Cognitive Software, semantic and complex Stroop, continuous performance, and polysomnography and CPAP devices.Results: The results indicated that both types of intervention can enhance cognitive functioning. However, a greater efficacy is obtained by combining the two methods compared with the exclusive application of medical treatment.


  1. References:
  2. Uncategorized References
  3. Ağargün MY, Kara H, Anlar Ö. The validity and reliability of the Pittsburgh Sleep Quality Index. Turk Psikiyatri Derg. 1996;7(2):107-15.
  4. Medicine AAoS. Task force: Sleep-related breathing disorders in adults. Recommendations for syndrome definition and measurement techniques in clinical research. Sleep. 1999;22:667-89.
  5. Buysse DJ, Reynolds CF, Kupfer DJ, Thorpy MJ. Clinical diagnoses in 216 insomnia patients using the International Classification of Sleep Disorders (ICSD), DSM-IV and ICD-10 categories: a report from the APA/NIMH DSM-IV Field Trial. Sleep: Journal of Sleep Research & Sleep Medicine. 1994.
  6. Duran J, Esnaola S, Rubio R, Iztueta Á. Obstructive sleep apnea–hypopnea and related clinical features in a population-based sample of subjects aged 30 to 70 yr. American journal of respiratory and critical care medicine. 2001;163(3):685-9.
  7. Alhola P, Polo-Kantola P. Sleep deprivation: Impact on cognitive performance. Neuropsychiatric disease and treatment. 2007;3(5):553.
  8. Lal C, Strange C, Bachman D. Neurocognitive impairment in obstructive sleep apnea. CHEST Journal. 2012;141(6):1601-10.
  9. Incalzi RA, Marra C, Salvigni BL, Petrone A, Gemma A, Selvaggio D, et al. Does cognitive dysfunction conform to a distinctive pattern in obstructive sleep apnea syndrome? Journal of sleep research. 2004;13(1):79-86.
  10. Dorrian J, Rogers NL, Dinges DF. Psychomotor vigilance performance: Neurocognitive assay sensitive to sleep loss: Marcel Dekker New York; 2005.
  11. Gagnon K, Baril A-A, Gagnon J-F, Fortin M, Decary A, Lafond C, et al. Cognitive impairment in obstructive sleep apnea. Pathologie Biologie. 2014;62(5):233-40.
  12. Lojander J, Kajaste S, Maasilta P, Partinen M. Cognitive function and treatment of obstructive sleep apnea syndrome. Journal of sleep research. 1999;8(1):71-6.
  13. Findley LJ, Barth JT, Powers DC, Wilhoit SC, Boyd DG, Suratt PM. Cognitive impairment in patients with obstructive sleep apnea and associated hypoxemia. CHEST Journal. 1986;90(5):686-90.
  14. Lindberg E. Epidemiology of OSA. 2010.
  15. Morin C, Blais F, Savard J. Are changes in beliefs and attitudes about sleep related to sleep improvements in the treatment of insomnia? Behaviour research and therapy. 2002;40(7):741-52.
  16. Saunamäki T, Jehkonen M. Depression and anxiety in obstructive sleep apnea syndrome: a review. Acta Neurologica Scandinavica. 2007;116(5):277-88.
  17. Iranzo A, Santamaria J. Severe obstructive sleep apnea/hypopnea mimicking REM sleep behavior disorder. Sleep. 2005;28(2):203-6.
  18. Meyer JS, Sakai F, Karacan I, Derman S, Yamamoto M. Sleep apnea, narcolepsy, and dreaming: regional cerebral hemodynamics. Annals of neurology. 1980;7(5):479-85.
  19. Bandura A. Human agency in social cognitive theory. American psychologist. 1989;44(9):1175.
  20. Bandura A, Walters RH. Social learning theory. 1977.
  21. Espie CA, Inglis SJ, Harvey L. Predicting clinically significant response to cognitive behavior therapy for chronic insomnia in general medical practice: Analyses of outcome data at 12 months posttreatment. Journal of Consulting and Clinical Psychology. 2001;69(1):58.
  22. Richards D, Bartlett DJ, Wong K, Malouff J, Grunstein RR. Increased adherence to CPAP with a group cognitive behavioral treatment intervention: a randomized trial. SLEEP-NEW YORK THEN WESTCHESTER-. 2007;30(5):635.
  23. Sharafkhaneh A, Richardson P, Hirshkowitz M. Sleep apnea in a high risk population: a study of Veterans Health Administration beneficiaries. Sleep medicine. 2004;5(4):345-50.
  24. Sharafkhaneh A, Giray N, Richardson P, Young T, Hirshkowitz M. Association of psychiatric disorders and sleep apnea in a large cohort. SLEEP-NEW YORK THEN WESTCHESTER-. 2005;28(11):1405.
  25. Bardwell WA, Moore P, Ancoli-Israel S, Dimsdale JE. Fatigue in obstructive sleep apnea: driven by depressive symptoms instead of apnea severity? American Journal of Psychiatry. 2003;160(2):350-5.
  26. Baran AS, Richert AC. Obstructive sleep apnea and depression. CNS spectrums. 2003;8(02):128-34.
  27. Aloia M, Arnedt J, Stepnowsky C, Hecht J, Borrelli B. Predicting treatment adherence in obstructive sleep apnea using principles of behavior change. Journal of clinical sleep medicine: JCSM: official publication of the American Academy of Sleep Medicine. 2005;1(4):346-53.
  28. Bourke R, Anderson V, Yang JS, Jackman AR, Killedar A, Nixon GM, et al. Cognitive and academic functions are impaired in children with all severities of sleep-disordered breathing. Sleep medicine. 2011;12(5):489-96.
  29. Golay A, Girard A, Grandin S, Metrailler J-C, Victorion M, Lebas P, et al. A new educational program for patients suffering from sleep apnea syndrome. Patient education and counseling. 2006;60(2):220-7.
  30. Tyrrell J, Poulet C, Pe J-L, Veale D. A preliminary study of psychological factors affecting patients' acceptance of CPAP therapy for sleep apnoea syndrome. Sleep medicine. 2006;7(4):375-9.
  31. McFadyen T, Espie C, McArdle N, Douglas N, Engleman H. Controlled, prospective trial of psychosocial function before and after continuous positive airway pressure therapy. European Respiratory Journal. 2001;18(6):996-1002.
  32. Engleman HM, Wild MR. Improving CPAP use by patients with the sleep apnoea/hypopnoea syndrome (SAHS). Sleep medicine reviews. 2003;7(1):81-99.
  33. Engleman HM, Asgari-Jirhandeh N, McLeod AL, Ramsay CF, Deary IJ, Douglas NJ. Self-reported use of CPAP and benefits of CPAP therapy: a patient survey. Chest. 1996;109(6):1470-6.
  34. Sivertsen B, Omvik S, Pallesen S, Bjorvatn B, Havik OE, Kvale G, et al. Cognitive behavioral therapy vs zopiclone for treatment of chronic primary insomnia in older adults: a randomized controlled trial. Jama. 2006;295(24):2851-8.
  35. Goodkind MS, Gallagher‐Thompson D, Thompson LW, Kesler SR, Anker L, Flournoy J, et al. The impact of executive function on response to cognitive behavioral therapy in late‐life depression. International journal of geriatric psychiatry. 2015.
  36. Espie CA, Inglis SJ, Tessier S, Harvey L. The clinical effectiveness of cognitive behaviour therapy for chronic insomnia: implementation and evaluation of a sleep clinic in general medical practice. Behaviour research and therapy. 2001;39(1):45-60.
  37. Quesnel C, Savard J, Simard S, Ivers H, Morin CM. Efficacy of cognitive-behavioral therapy for insomnia in women treated for nonmetastic breast cancer. Journal of consulting and clinical psychology. 2003;71(1):189.
  38. Vincent N, Lewycky S. Logging on for better sleep: RCT of the effectiveness of online treatment for insomnia. Sleep. 2009;32(6):807-15.
  39. Beebe DW, Gozal D. Obstructive sleep apnea and the prefrontal cortex: towards a comprehensive model linking nocturnal upper airway obstruction to daytime cognitive and behavioral deficits. Journal of sleep research. 2002;11(1):1-16.
  40. Manber R, Edinger J, Gress J, San Pedro-Salcedo M, Kuo T, Kalista T. Cognitive behavioral therapy for insomnia enhances depression outcome in patients with comorbid major depressive disor-der and insomnia. Sleep. 2008;31(4):489-95.
  41. Harvey AG, Tang NK. Cognitive behaviour therapy for primary insomnia: can we rest yet? Sleep medicine reviews. 2003;7(3):237-62.
  42. Hofmann SG. The importance of culture in cognitive and behavioral practice. Cognitive and Behavioral Practice. 2006;13(4):243-5.