Which Should You Treat First—Insomnia or Sleep Apnea? Science Has Surprising Answers

If you’ve ever struggled with both sleep apnea and insomnia, you’re not alone. There’s actually a medical term for this double burden: COMISA, or comorbid insomnia and sleep apnea. And research shows it’s not just frustrating — it’s linked with worse health outcomes, from higher cardiovascular risks to poorer mental health.

So how do we treat COMISA? Should we target the sleep apnea with CPAP first, or address the insomnia through therapy? And what happens if both need to be tackled at the same time? Let’s explore what the latest research and clinical experience tell us.

What Is COMISA?

• Insomnia is defined as trouble falling asleep, staying asleep, or waking up too early at least three nights a week for three months or longer.

• Sleep apnea occurs when throat muscles relax during sleep, leading to airway obstruction and multiple breathing pauses throughout the night. This drives oxygen dips, frequent awakenings, and next-day exhaustion.

• COMISA is when both occur together — essentially the perfect storm of disrupted sleep.

People living with COMISA often feel trapped in a cycle. Insomnia elevates stress and anxiety around sleep, while sleep apnea adds repeated physical interruptions to rest. Together, they magnify risks for depression, anxiety, cardiovascular disease, and decreased longevity.

Why This Matters Clinically

COMISA isn’t just “twice as bad” — it’s its own condition. Studies show that people with both insomnia and sleep apnea have higher mortality risks than those with either disorder alone.

This makes timely intervention essential. But the real challenge lies in the next question: which disorder do we treat first?

The “Which First?” Debate

Historically, sleep apnea has often been treated first, especially if it’s moderate-to-severe and associated with strong cardiovascular risk. The thinking here is simple: correct the airway problem and sleep should consolidate, allowing insomnia symptoms to improve on their own. In fact, about one-quarter to one-third of patients with COMISA see their insomnia resolve once their sleep apnea is treated.

But newer research suggests that this isn’t always the best path. Insomnia can erode CPAP tolerance: it’s difficult to keep a mask on all night when you’re lying awake frustrated, clock-watching, and hyperaware of every discomfort. In these cases, treating insomnia first — or at least in tandem — may improve adherence to sleep apnea therapy.

CBTI: The Gold Standard for Insomnia

Cognitive Behavioral Therapy for Insomnia (CBTI) remains the most evidence-based, first-line intervention for chronic insomnia. It focuses on:

• Cognitive strategies: reshaping maladaptive beliefs about sleep (e.g., “I must get 8 hours or I’ll be a wreck”).

• Behavioral strategies: limiting time in bed to actual sleep time, breaking cycles of rumination, and consolidating sleep pressure.

Digital CBTI programs are now being studied — with evidence showing they work nearly as well as face-to-face therapy and expand access for people who might not otherwise see a sleep psychologist. Excitingly, recent trials have shown strong results in patients with COMISA, not just standalone insomnia.

ACT: An Adjunct for Sleep Anxiety

Acceptance and Commitment Therapy (ACT) has started to play a growing role as an adjunct treatment for sleep issues. While CBTI challenges sleep-related thoughts directly, ACT approaches them differently:

• Instead of “fighting” the sleeplessness, ACT encourages acceptance of occasional insomnia.

• Patients learn to defuse from catastrophic thoughts like “I’ll never sleep tonight” and instead cultivate neutrality: “This might just be a tricky night — and I’ll cope.”

• Practical techniques involve gently redirecting the mind to calming, nonjudgmental streams of thought (like nostalgic memories, creative visualizations, or favorite stories).

This approach is particularly useful for patients whose racing minds aren’t only about sleep, but also about daytime stressors that resurface the moment the lights go out.

Practical Principles to Guide Treatment

So, should you treat sleep apnea first or insomnia first? The answer — frustratingly — is that there isn’t a onesizefitsall solution. Here are some guiding principles supported by clinical practice and research:

• Severe sleep apnea (particularly when cardiovascular risk is high): treat OSA first. Insomnia may improve once nightly breathing stabilizes.

• Insomnia interfering with CPAP tolerance: begin with CBTI. Improving sleep consolidation can make CPAP use more bearable and sustainable.

• Milder cases or high sleepanxiety component: consider a combined approach — tackle apnea treatment in tandem with CBTI (and ACT if anxiety is central).

• Digital CBTI programs expand access for those without local specialists and show promise in COMISA populations.

Practical Principles to Guide Treatment

COMISA is more than just the sum of its parts. Left untreated, it multiplies both medical and mental health risks. The good news? Evidence-based therapies like CBTI, ACT, and sleep apnea treatment — whether CPAP or alternatives — can be strategically combined to break the cycle.

The future is pointing toward individualized sequencing: not “insomnia or sleep apnea first,” but asking instead: which barrier is blocking this patient’s recovery right now? Address that — and often, the rest begins to unlock.

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