PAP therapy remains the gold standard and most commonly prescribed treatment for obstructive sleep apnea. However, low adherence presents a significant challenge for sleep medicine clinicians, with most published studies reporting adherence between 40% and 50%. Numerous interventions to improve PAP use have been developed, and forward-thinking sleep centers have proactively begun to establish programs to maximize PAP adherence among their patients. Although not yet widely disseminated, cognitive-behavioral treatments (CBTs) for PAP adherence are among the most promising interventions developed to date. The benefits of CBTs for PAP adherence are evident in the theoretical underpinnings and extant evidence base. Incorporating CBT into a comprehensive PAP adherence program can be facilitated by following a practice model that maximizes patient outcomes.
EFFORTS TO IMPROVE ADHERENCE
Several high-quality reviews of factors related to PAP use are available in the literature. A review of 17 randomized studies (total N = 1,050) evaluated supportive, educational, and behavioral strategies to improve PAP adherence and reached several conclusions.1 First, although patient education is an essential aspect of chronic disease management, stand-alone educational interventions do not appear to improve PAP adherence. Second, studies to date suggest that ongoing supportive interventions enhance PAP use by an average of 0.59 hour per night. Third, CBTs increased PAP use by an average of 2.92 hours per night and reduced PAP failure by nearly 50% at 4 and 12 weeks. In addition to these nonpharmacological strategies, three studies have evaluated the use of hypnotic sleep aids to improve PAP adherence, with promising but mixed results.2-4
WHAT ARE COGNITIVE-BEHAVIORAL TREATMENTS?
Cognitive-behavioral treatments are a broad class of interventions designed to create lasting behavior change by modifying the ways patients think, feel, and behave. Although CBTs were initially developed to treat mental health conditions, the past two decades have seen an explosion of evidence-based CBTs in more traditional medical domains—even in the absence of a frank mental health disorder. For example, evidence supports the use of CBT to increase health behaviors such as exercise, diet, and medication adherence in conditions including cancer, cardiovascular disease, diabetes, HIV, obesity, and chronic pain, just to name a few. To facilitate use of CBTs in medical settings, the Centers for Medicare and Medicaid Services (CMS) in 2002 introduced distinct CPT codes for these services. Many CBT providers, primarily psychologists, have adopted these new CPT codes in some or all of their patients.
CBTS FOR SLEEP DISORDERS
Among sleep practitioners, CBT is best known as the gold standard treatment for chronic insomnia, including insomnia occurring in the context of other psychiatric, medical, or sleep disorders. Four head to head randomized controlled trials (RCTs) (including three published in JAMA) as well as a meta-analysis have supported the long-term efficacy of CBT relative to both older benzodiazepine as well as newer non-benzodiazepine hypnotic agents in the treatment of chronic insomnia.5-9 Further, the 2008 AASM Clinical Guideline for the Management of Chronic Insomnia in Adults recommends that cognitive and behavioral therapies be utilized in all insomnia patients, including those undergoing a short-term or long-term treatment with hypnotic sleep aids.10 CBTs also have empirical support in the treatment of chronic nightmares, nocturnal panic, circadian rhythm disorders, and other sleep disorders. To place CBTs for PAP adherence in context, we will next consider psychological factors related to PAP use.
PSYCHIATRIC CONDITIONS, PSYCHOLOGICAL DISTRESS, AND PAP ADHERENCE
In the broader medical literature, the relationship between depression and poorer medication adherence is well-documented. However, possibly due to a paucity of high-quality studies, research investigating the relationship between depressive symptoms and PAP adherence has produced inconsistent results, with some studies supporting a relationship and others not. Nonetheless, clinical experience suggests anxious symptomatology is a common barrier to effective PAP use. For example, claustrophobia is a well-known barrier to PAP adherence.11 Similarly, a recent case control study found that patients experiencing PTSD were significantly less likely to use CPAP regularly (>4 hours/night on 70% of nights) than were patients without PTSD (26.7% vs 53.3%, p = .01).12 Importantly, these authors hypothesized that concomitant insomnia may underlie poor PAP adherence in this population. This hypothesis is notable in light of recent reviews concluding that approximately 50% of patients referred for evaluation of OSA report symptoms suggestive of chronic insomnia.13 In a study conducted at Johns Hopkins Hospital, self-reported insomnia symptoms were associated with poorer PAP use at clinic follow-up.14 In terms of developing a comprehensive practice model, it is essential to develop a strategy to treat the many patients suffering from comorbid insomnia and OSA. Notably, CBT for insomnia and CBT for PAP adherence can be easily integrated by a behavioral sleep specialist.15
COGNITIVE-BEHAVIORAL AND PSYCHOLOGICAL ASPECTS OF PAP ADHERENCE
In addition to the aforementioned mental health symptoms, ample evidence supports psychological variables such as patient attitudes, beliefs, knowledge, perceived importance, perceived risks and benefits, and perceived self-efficacy in understanding and predicting PAP adherence (see reference 16 for a review). Two recent prospective studies employed theoretical models well-validated in numerous health domains and are of particular interest. In the first, psychological variables measured pre-titration accounted for 21.8% of the variance in PAP use at clinical follow-up, whereas biomedical indices alone accounted for 10% of variance in PAP use.17 More recently, among 100 newly diagnosed OSA patients prescribed PAP, a decision-tree algorithm using age and two psychological variables (emotional reactivity and disease perceptions) accurately classified 85.7% of eventual nonadherers when these psychological variables were measured pre-titration.18 These striking findings regarding psychological risk for poor PAP adherence are receiving increasing research attention and clinical implementation among sleep specialists. From a public health perspective, the ability to identify efficiently patients likely to fail at PAP and thus in need of additional support could substantially improve the long-term cost-effectiveness of sleep medicine interventions. Indeed, as technological advancements such as APAP increase access to PAP therapies, patients, payors, and the public will benefit by ensuring that patients at risk for poor adherence are not prescribed PAP prematurely. This latter point may be especially pertinent as primary care physicians become increasingly involved in the diagnosis and management of OSA.
COGNITIVE-BEHAVIORAL AND MOTIVATIONAL INTERVENTIONS TO IMPROVE PAP ADHERENCE
Several studies suggest that theory-driven CBTs can improve adherence to PAP therapy. In an randomized pilot study of CBT for CPAP, Aloia and colleagues found no differences in PAP use at 1 or 4 weeks, but at 12 weeks patients in the treatment condition used PAP an average of 3.2 hours more than patients who underwent treatment as usual (p <.04).19 The intervention, motivational enhancement for CPAP (ME-CPAP), consists of two 45-minute treatment visits with a psychologist and a 15-minute follow-up telephone call with a trained nurse.20 This intervention is based on an evidence-based approach called motivational interviewing (MI).21 In MI, the provider seeks to resolve ambivalence and guide patients from simply considering PAP to active engagement in their own self-care. In addition to establishing concrete goals and rewards for small steps with CPAP, providers seek to identify future life goals such as parenthood or grandparenthood and highlight discrepancies between these stated goals and PAP use. A larger study of ME-CPAP replicated the initial positive results when contrasted to treatment as usual.22 However, no significant differences were detected between ME-PAP and an educational control intervention. One obvious reason for the relative equivalency between CBT and education was that CBT was not begun until 1 week after PAP initiation. Thus, patients had already gained substantial exposure to PAP by the time CBT was initiated.
In the first study to initiate CBT prior to titration, Richards et al23 administered CBT in a group format to 100 newly diagnosed OSA patients. This intervention targeted distorted beliefs regarding sleep apnea and PAP, optimism regarding PAP, and sleep knowledge. Groups consisted of approximately 10 newly diagnosed OSA patients as well as their bed partners. The intervention consisted of two 60-minute treatment sessions conducted approximately 1 week apart. Multimedia educational strategies also were employed, including a slide show, machine demonstration, and video that presented model patients presenting stories of successful adaptation to PAP. Only four patients randomized to CBT did not complete their titration, whereas 15 in treatment as usual refused titration. Further, CBT resulted in over a 200% increase in PAP use at 4 weeks relative to treatment as usual (5.38 hrs vs 2.51 hrs, p <.0001). Psychologists experienced in CBT administered all treatment.
More recently, Olsen et al24 found that individual CBT initiated prior to titration also resulted in more patients completing their titrations and greater long-term adherence. The first two sessions of this MI-based intervention emphasized building motivation to change and strengthening that commitment. Each visit was 30 to 45 minutes in duration, and a third booster session lasted 20 to 30 minutes. Relative to patients randomized to treatment as usual, patients who underwent CBT were six times more likely to initiate PAP and demonstrated 50% greater nightly PAP use at 3-month follow-up (4.63 hrs vs 3.16 hrs, p <.001). Gains were maintained at 6-month follow-up and remained clinically significant at 12 months. These authors speculate that one reason why participants in this study may have experienced less benefit than patients in the Richards et al23 study is that treatment was not delivered by a psychologist but instead administered by experienced sleep nurses, trained and closely supervised by a sleep psychologist. Nonetheless, in light of the well-documented shortage of behavioral sleep specialists, this study is notable in that it suggests a possible dissemination pathway to increase access to CBT. Relatedly, patient self-management tools and technology-based CBT delivery formats continue to be explored and will play an increasing role in the future.25
CASE STUDY: A COMPREHENSIVE MODEL IN ACTION
At the Center for Sleep Disorders at Pulmonary Disease and Critical Care Associates, the objectives of our evidence-based PAP Success program are to optimize the titration experience as well as ensure early intervention to resolve any problems identified during follow-up. Prior to titration, patients diagnosed with OSA undergo a brief PAP initiation visit that focuses on PAP education and mask desensitization. In our center, this visit is conducted by an experimental psychologist (PhD)/RPSGT working under the supervision of a physician or licensed psychologist/behavioral sleep specialist. Patients test several masks during initial behavioral desensitization, and their selected mask is then used to begin the titration on the night of their study. Following titration, we monitor objective PAP adherence in house, either via SD card or wireless modem. When suboptimal adherence is identified, we first resolve any technical barriers to adherence such as mask leak, then typically refer patients to our behavioral sleep specialist for CBT. Like an increasing number of academic and other community centers, following behavioral sleep consultation and CBT, we employ PAP NAPS for carefully selected patients with mental health diagnoses, who continue to experience difficulty with PAP. Of course, we also refer for alternative treatments such as an oral appliance when appropriate. To date, our comprehensive program has yielded the following benefits:
- Virtually all patients recommended PAP are willing to undergo titration, and PAP adherence exceeds published rates.
- Patient satisfaction scores are very high, which has resulted in many patient-to-patient referrals.
- Referring physicians also report high satisfaction with our comprehensive approach. In a relatively brief time, we have begun to be recognized as a preferred center in our area.
- We are also the only community-based center in our area with an active behavioral sleep program, further differentiating us in the marketplace.
- During our recent AASM accreditation site visit, our experienced site visitor provided very positive feedback on our comprehensive, interdisciplinary PAP Success program.
- A final, emerging benefit is our ability to leverage our success in patient care into partnering relationships with entities that outsource sleep medicine care.
It is important to note that we were able to build our interdisciplinary model from the ground up. We thus established an active PAP adherence program and vibrant behavioral sleep program without the resistance common in single discipline or long-established centers. In such environments, past success can lead to complacency, with the default assumption being that what worked in the past will continue to work in the future. In our rapidly changing health care environment, this is at best a tenuous assumption. Candid peer-to-peer dialogue and creative adaptation of emerging best practices are necessary to ensure a successful program expansion.
CONCLUSIONS AND FUTURE DIRECTIONS
Interest in improving sleep medicine patient care and PAP adherence has never been higher. As evidenced by the recently proposed AASM integrated delivery model, a team approach is necessary to ensure optimal management of sleep disorders as chronic medical conditions. Five RCTs support the effectiveness of CBTs for PAP adherence, more than any other PAP adherence intervention to date. Further, these results parallel findings regarding adherence interventions in the broader medical literature. Among forward-thinking sleep centers, comprehensive practice models continue to evolve to address such pragmatic issues as staffing, training, feasibility, and so on. The time for an interdisciplinary approach to sleep disorders medicine has arrived. For centers committed to maximizing outcomes for the full range of sleep disorders, a robust behavioral sleep program is an essential component of a comprehensive approach.
Emerson M. Wickwire, PhD, ABPP, CBSM, is sleep medicine program director at Pulmonary Disease and Critical Care Associates in Columbia, Md, and assistant professor, part-time, at Johns Hopkins School of Medicine. He serves on the Education Committees of the American Academy of Sleep Medicine and the National Sleep Foundation. Wickwire can be reached at firstname.lastname@example.org.
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