A retrospective chart review links auto-adjusting dual-pressure, auto-bilevel, and adaptive servo-ventilation positive airway pressure device use to large decreases in insomnia severity for patients who believed psychological factors were the root cause of their sleeplessness.

Patients with sleep-onset insomnia—that is, they can’t fall asleep at bedtime—typically blame psychological factors. For example, they can’t turn off their minds or report “racing thoughts” even though they want to go to sleep.

Typical treatment for patients with sleep-onset insomnia are prescription or over-the-counter sleep aids and/or cognitive behavioral therapy for insomnia (CBT-I), but neither of these methods is fully satisfactory for many patients. Pharmaceuticals may cause side effects and lead to over-dependence, and qualified CBT-I providers are not available or do not have timely appointment openings in many parts of the country.

Barry Krakow, MD, and colleagues have since 2001 theorized, and shown evidence for, the idea that a prevalent cause for insomnia is comorbid sleep-disordered breathing. And they have had success treating patients with sleep-maintenance insomnia—that is, patients who can’t stay asleep for a full night—with positive airway pressure (PAP) technology. But sleep-onset insomnia patients have not responded as favorably to PAP therapy.

Krakow and coauthors conducted a retrospective chart review to see if advanced PAP technology, specifically auto-adjusting dual-pressure, auto-bilevel (ABPAP), and adaptive servo-ventilation device (ASVPAP) would help severe sleep-onset insomnia patients. They reviewed charts of 74 patients, all of whom affirmed severe behavioral and psychological signs of insomnia, as well as psychiatric symptoms or conditions such as depression, anxiety, claustrophobia, panic attacks, and post-traumatic stress disorder. All patients had failed continuous PAP or bilevel PAP. Because advanced PAP devices eliminate expiratory pressure intolerance, Krakow and coauthors theorized that patients with sleep-onset insomnia and comorbid sleep-breathing disorders may respond better to these devices over traditional PAP.

The study “A Novel Therapy for Chronic Sleep-Onset Insomnia” is published in The Primary Care Companion for CNS Disorders.


The objective of this study was to evaluate the potential association between advanced PAP technology and decreases in sleep-onset insomnia severity in a sample of predominantly psychiatric patients with comorbid sleep apnea. The study was conducted to encourage future research on the subject, Krakow says, and because there is so little research on the topic currently.

“We knew from our own experience clinically that when we use these advanced PAP devices, like auto bilevel and ASV, that they are more comfortable for the sleep onset insomnia patients. They report greater ease of use compared to CPAP, a device that triggers claustrophobic, panic, or even traumatic experiences in these types of patients.,” says Krakow in an interview with Sleep Review. “We wanted to get this idea out there for potential research as it’s not a controlled trial, it’s a retrospective chart review. Nonetheless we want sleep specialists to know that this approach seems ripe for research and even for potential clinical use in some cases.”

Surprising Results?

The results found advanced PAP users showed notably greater decreases in global insomnia severity compared to partial users. The researchers note that both global and sleep-onset insomnia severity decreased below moderate levels in advanced PAP users compared to partial users (whose outcomes persisted at moderately severe levels). The research team was not expecting the people with partial advanced PAP technology use to show such promising results as well, Krakow says.

“We weren’t expecting the people with partial use to show such decent results. We thought their results would be so-so. But, in fact, when it came to the sleep-onset insomnia score, they had a large effect. When it came to the total ISI [Insomnia Severity Index] score, they had a large effect,” he says. “[These patients] averaged 11 to 12 hours of PAP use per week and still got excellent responses.”

Krakow notes that the research does not prove the advanced PAP devices caused the improvement because researchers could not detect other things the participants may have used , such as medication, for the insomnia. However, Krakow says, “In general, the people who used it more hours, the full-time users, had the most dramatic responses, but the partial users’ response was very good, if in fact it is related to the advanced device.”

Study Limitations

As this research study was a retrospective chart review, the results are not conclusive but may be a foundation for future research. “We can only use the technical, statistical categorization called association. The two things were associated with each other. The person used the device and there was a drop in their insomnia scores. It looks like there could be a relationship here,” Krakow says. “It’s a limitation and we cannot at this point talk about causality, but this pilot work is a stepping stone.”

Sleep and Mental Health

The authors suggest that a multi-faceted treatment approach may help successfully treat chronic sleep-onset insomnia. So the sleeping aids and CBT-I that are frequently employed today still have a role in treating sleep-onset insomnia patients. “As much as we are pleased that somebody could use PAP and get the kinds of benefits that we believe are associated with advanced devices, there is is still a lot of psychological variables in play for these patients. I believe many of these individuals would benefit from combination therapy,” says Krakow. “If they could receive both the psychological and the physiological treatment, I would expect them to have an even more sustainable response.”

A multi-faceted approach would entail sleep medicine specialists, behavioral sleep specialists, and mental healthcare providers working together. Some sleep centers may not be comfortable or are uncertain of how to handle the mental health aspects of sleep disorder treatment, and may therefore be more likely to prescribe a medication, Krakow says. “I think that’s a very narrow and less fruitful treatment option compared to somebody meeting with a therapist, learning about cognitive behavioral therapy for insomnia, learning about how to process your emotions in a more healthy manner, and learning how to use PAP therapy. All of these treatments overlap and lead to better long-term results,” Krakow says. “As we noted in the paper, many of the patients who were in this study had poor mental health, which probably steered them away from considering a possible sleep apnea diagnosis”

Cooperation among healthcare providers in sleep and mental health may be key to treating sleep disorders patients in the future. “It’s not to say that there aren’t a lot of people looking at this overlap, but a major gap remains that still is not being filled by either field,” says Krakow. “Building bridges between these fields would be an essential step.

Future Research and Implications

To further explore the use of advanced PAP technology to treat chronic insomnia, Krakow suggests the three following areas of insomnia be studied: sleep onset problem, sleep maintenance problem, and early morning awakening. “All 3 types of insomnia have their own distinct features. I think it’s very important that PAP research be examined in all 3 types,” says Krakow. “Currently, there is little research on sleep-onset insomnia and or on the early morning awakening problems as they might respond to PAP. Moving forward prospective, randomized controlled trials are very much needed.”

“Currently, we are conducting an randomized controlled trial, comparing CPAP to ASV in the treatment of chronic insomnia,” says Krakow. “We hope to conclude the study some time next year.”

Cassandra Perez is associate editor for Sleep Review. CONTACT [email protected]