COMISA: How to Manage Insomnia and Sleep Apnea Together

Imagine lying awake at night, your mind racing, while also gasping for air every few minutes. You’ve been told you have sleep apnea, so you’re using a CPAP machine-but it’s making your insomnia worse. Or maybe you’ve been told you have insomnia, so you’re trying CBT-I, but you still wake up choking in the middle of the night. This isn’t just bad luck. It’s COMISA-Comorbid Insomnia and Sleep Apnea. And it’s more common than you think.

What Exactly Is COMISA?

COMISA isn’t just having two sleep problems at once. It’s when insomnia and obstructive sleep apnea (OSA) interact in a way that makes both worse. About 39% to 58% of people diagnosed with OSA also have clinical insomnia, according to research from Flinders University. That means nearly half of all sleep apnea patients are stuck in a cycle: the CPAP mask irritates their skin and disrupts sleep onset, while the frequent breathing pauses keep them from staying asleep. Meanwhile, their insomnia makes them hyper-aware of every breath, every rustle, every beep from the machine.

This isn’t a coincidence. Studies show that when you treat one condition without the other, success rates drop dramatically. CPAP works for 85-90% of people with OSA alone-but only 42.7% of COMISA patients stick with it. Why? Because the machine doesn’t fix the racing thoughts, the muscle tension, or the fear of not falling asleep. And CBT-I, which helps 70-80% of people with pure insomnia, doesn’t stop the breathing pauses that wake you up every 45 seconds.

Why Standard Treatments Fail

Most doctors treat sleep apnea first-CPAP, then maybe a mouthpiece. They treat insomnia second-sleep hygiene, maybe a pill. But in COMISA, this sequence backfires.

When you start CPAP without addressing insomnia, 27% of patients report their sleep gets worse. Why? The mask feels claustrophobic. The air pressure wakes them up. The machine beeps. They start associating bed with frustration, not rest. Meanwhile, if you only do CBT-I, the breathing events keep happening. You’re training your brain to sleep better, but your body is still being jolted awake by low oxygen levels. It’s like trying to meditate while someone’s poking you every few minutes.

And here’s the kicker: people with COMISA are more likely to have anxiety, depression, or trauma-related insomnia. One study found that patients with high anxiety saw only a 45% improvement in insomnia with CBT-I-compared to 78% for those without anxiety. So standard approaches aren’t just incomplete-they’re often setting people up to fail.

The Only Proven Solution: CBT-I + CPAP Together

The data is clear: the best way to treat COMISA is to tackle both conditions at the same time. Not one after the other. Not “try CPAP for a month, then see.” Concurrent treatment-starting CBT-I and CPAP on day one-doubles your chances of success.

A 2020 randomized trial showed that when patients got five sessions of CBT-I combined with behavioral coaching for CPAP use, they increased their nightly CPAP usage by 1.2 hours on average. Insomnia symptoms dropped by 54%. Twelve weeks later, 63% of those in the combined group had their insomnia go into remission. Only 29% did with CPAP alone.

CBT-I for COMISA isn’t the same as for regular insomnia. It’s modified. Therapists teach you how to:

• Reduce fear of the CPAP machine using exposure techniques
• Use stimulus control to re-associate bed with sleep, not frustration
• Practice relaxation methods that work even when the machine is on
• Adjust sleep schedule to consolidate sleep, which actually reduces OSA severity by up to 15%

And CPAP settings are adjusted too. Modern machines like ResMed’s AirSense 11 can detect sleep stages and lower pressure during REM sleep-when apneas are most common. Some even ramp up pressure slowly over 15 minutes, making it easier to fall asleep with the mask on.

What If You Can’t Get CBT-I?

Only 12% of COMISA patients have access to a psychologist trained in CBT-I for sleep apnea. Wait times can be over 14 weeks. But digital CBT-I platforms like Sleepio and Somryst are changing that.

Somryst’s COMISA module, launched in August 2023, syncs with CPAP data. It tracks how many hours you use the machine, how often you wake up, and adjusts lessons in real time. In a 2023 JAMA study, it helped 65% of mild COMISA patients (AHI 5-15) achieve insomnia remission. But for moderate to severe OSA (AHI >15), the success rate dropped to 38%. That means digital tools work best when your apnea isn’t too extreme.

If you can’t get in-person CBT-I, try:

• Using a CPAP machine with a built-in ramp feature
• Trying a nasal pillow mask instead of a full-face mask
• Practicing 10 minutes of diaphragmatic breathing before bed
• Keeping a sleep log to identify patterns (e.g., “I always take off the mask after 2 hours”)

These aren’t replacements for therapy-but they’re bridges.

Other Options? Orexin Antagonists and More

In December 2023, the FDA approved suvorexant (Belsomra) for COMISA patients. It’s an orexin antagonist-a new class of drug that reduces wakefulness signals in the brain. In trials, when combined with CPAP, it helped 57% of patients achieve insomnia remission versus 33% with CPAP alone.

But it’s not a first-line treatment. Side effects include next-day drowsiness, dizziness, and potential for dependence. It’s also expensive-$400-$600 a month without insurance. Most insurers won’t cover it unless you’ve tried CBT-I and CPAP first.

Mandibular advancement devices (MADs) help mild to moderate OSA. But they don’t fix insomnia. Neurostimulation implants like Inspire are for severe OSA patients who can’t tolerate CPAP-but they don’t address sleep maintenance issues. So while these tools have their place, they’re not the solution for most COMISA cases.

Why So Many People Are Still Misdiagnosed

Most people with COMISA wait over 7 years to get the right diagnosis. Why?

• Primary care doctors see snoring and say, “You have sleep apnea-get a CPAP.”
• Therapists see insomnia and say, “Try sleep restriction and CBT-I.”
• Sleep labs focus on AHI scores and ignore insomnia severity scores (ISI ≥15).

Many patients are told, “You’re just stressed.” Or, “You’re not using your CPAP right.” But the real issue? No one’s asking: “Do you have trouble falling asleep *and* staying asleep *while* using the machine?”

That’s why tools like the COMISA Severity Index are being adopted. It’s a 10-minute questionnaire that checks for both conditions. But only 28% of U.S. sleep centers have formal referral pathways between sleep physicians and behavioral sleep specialists.

What’s Changing in 2025?

Big shifts are happening. In January 2024, Medicare started reimbursing for integrated COMISA treatment with new billing codes (G2212-G2214). Each session is now worth $125-$185. That’s pushing clinics to hire sleep navigators-coordinators who link psychologists, sleep techs, and pulmonologists.

Programs like Mayo Clinic’s Integrated Sleep Program cut treatment start time from 11 weeks to 3 weeks. UnitedHealthcare found that COMISA patients on combined therapy used 22% less healthcare overall-saving $1,843 per person per year.

And the research keeps growing. The COMBINE trial, currently enrolling 300 patients, will soon tell us whether starting CBT-I and CPAP together is better than treating OSA first. Early results suggest it is.

Machine learning models are now predicting COMISA with 78% accuracy based on sleep logs, heart rate variability, and CPAP usage patterns. That means in the next few years, AI might flag your risk before you even walk into a clinic.

What You Can Do Right Now

If you suspect you have COMISA:

1. Get a sleep study (polysomnography) that includes an Insomnia Severity Index (ISI) score.
2. If your AHI is ≥5 and your ISI is ≥15, you likely have COMISA.
3. Ask your sleep doctor: “Do you offer combined CBT-I and CPAP treatment?”
4. If not, ask for a referral to a behavioral sleep medicine specialist.
5. Start using CPAP with a ramp feature and a comfortable mask-don’t wait for therapy to begin.
6. Download a free CBT-I app like Sleepio or Somryst and start the modules.

You don’t need to wait for the perfect clinic. You don’t need to suffer for another year. COMISA is treatable-but only if you treat both conditions together.

Common Myths About COMISA

• Myth: “I can fix my insomnia after I get used to CPAP.”
  Truth: CPAP often makes insomnia worse at first. Waiting makes it harder to adapt.
• Myth: “I don’t need therapy-I just need a better mask.”
  Truth: Mask comfort helps, but if your brain is wired to fear sleep, no mask will fix that.
• Myth: “COMISA is rare.”
  Truth: It affects nearly half of all OSA patients. If you have both, you’re not alone.
• Myth: “CBT-I won’t work if I have apneas.”
  Truth: CBT-I reduces sleep fragmentation, which lowers OSA severity. It’s a two-way street.

Final Thought: You’re Not Broken

You’re not lazy. You’re not failing at CPAP. You’re not “just anxious.” You have COMISA-a complex, real, and treatable condition. The system hasn’t caught up yet. But the science has. And you don’t need to wait for the system to change to start feeling better. Start with one step: ask your doctor if you have both conditions. Then ask if they can help you treat them together. That’s the only path that works.