More common than you might think
In a meta-analysis of 37 studies, 38% of people with sleep apnea also had insomnia. That's close to four in ten.
Each disorder can feed the other. Apnea causes repeated brief awakenings, and broken nights can lead to unhelpful habits: lying awake in bed for long stretches, waiting for sleep to come, dreading bedtime. Over time, the brain learns to link bed with being awake. That conditioning can outlast the apnea itself: once CPAP has fixed your breathing, the insomnia may still be there.
Sometimes it's CPAP itself that makes things harder at first. The mask, the air pressure, the noise, a feeling of being closed in: any of these can make bedtime stressful and keep you from falling asleep.
Insomnia or sleep apnea: how to tell them apart
The two can occur together, and only a doctor can sort out which is which. A few pointers:
| Symptom | Insomnia | Sleep apnea |
|---|---|---|
| Trouble falling asleep | Common | Less typical |
| Waking up at night | Common | Common (often not remembered) |
| Daytime sleepiness | Tiredness more than sleepiness | Common |
| Snoring | Unrelated | Common |
| Breathing pauses noticed by a bed partner | No | Warning sign |
What is CBT-I?
Cognitive behavioral therapy for insomnia (CBT-I) is the recommended first-line treatment for chronic insomnia, according to both the American Academy of Sleep Medicine and the European insomnia guideline. It isn't a sleeping pill, and it isn't just relaxation: it's a structured program, spread over a few weeks, that goes after whatever is keeping your insomnia going.
The idea is that chronic insomnia is often held in place by habits and thoughts that have built up over time: hours spent in bed waiting to fall asleep, thoughts like "tomorrow will be a disaster," a bed your brain now links with being awake. CBT-I takes these apart one at a time, week by week.
Illustration being redrawn
3 columns: sleep restriction (clock and bed), stimulus control (bed and arrow), cognitive restructuring (brain and speech bubble)
trois-piliers-tcci · 1000×500px · infographic
The three pillars of CBT-I
Sleep restriction
It sounds backward, but it works: for a while, you cut down the time you spend in bed so it matches the time you actually sleep. If you sleep 5 hours but stay in bed for 9, your sleep is spread thin. Restricting your time in bed builds up sleep pressure, so you fall asleep faster and wake up less. The window is then widened, step by step. In the first few weeks it often makes people sleepier, so take care behind the wheel. If you're already drowsy during the day, as many people with sleep apnea are, your therapist will adjust this step.
Stimulus control
Your brain has learned to link bed with being awake and frustrated. This step rebuilds the link between bed and sleep: go to bed only when you feel sleepy, get up if you haven't fallen asleep after roughly 15 to 20 minutes, and keep your bed for sleep.
Cognitive restructuring
Thoughts like "I'll never get to sleep" or "if I don't sleep, tomorrow will be a disaster" fuel anxiety and keep you awake. CBT-I helps you spot them and replace them with more realistic ones.
Why CBT-I matters if you have sleep apnea
CPAP keeps your airway open. It can't undo the habits and thoughts that keep insomnia going, and that's where CBT-I comes in.
- → Insomnia that lingers on CPAP: your apneas are treated, but you still can't fall asleep, or you keep waking up during the night. The insomnia has taken on a life of its own, and CBT-I targets it directly.
- → A mask that's hard to get used to: anxiety, a smothering feeling, dread at bedtime. CBT-I works on these thoughts and on avoidance habits, and can make bedtime less of an ordeal.
- → Better CPAP use: in an Australian trial of 145 people with both sleep apnea and insomnia, those who had four CBT-I sessions before starting CPAP went on to use it 61 minutes longer per night, on average.
CBT-I or sleeping pills?
Sleeping pills work quickly, but they don't treat what's keeping the insomnia going. Belgium's guideline for general practice (WOREL), revised in June 2026, reserves them for severe, short-term insomnia, for one week at most. Sleep apnea adds another reason for caution: according to the Belgian drug formulary published by the CBIP/BCFI, untreated obstructive sleep apnea is a contraindication to benzodiazepines, which can make apneas worse.
| Sleeping pills | CBT-I | |
|---|---|---|
| How fast it works | Quickly | Gradually, over a few weeks |
| How long it lasts | Tolerance after a few weeks of use | Benefits last after treatment ends |
| Dependence | A real risk with long-term use | None |
| Side effects | Drowsiness, memory problems, falls | Temporary sleepiness early in sleep restriction |
| Effect on sleep apnea | Can make apneas worse (benzodiazepines) | Can help you use CPAP more |
CBT-I is the first-line treatment for chronic insomnia recommended by the American Academy of Sleep Medicine (2021) and the European insomnia guideline (2023). In Belgium, the WOREL guideline (2026) makes a drug-free approach the foundation of treatment, with CBT-I at its core. Sleeping pills come second, and only for a short time.
What you can expect
In a meta-analysis of 20 trials involving 1,162 adults, CBT-I cut the time it took to fall asleep by about 19 minutes, and the time spent awake in the middle of the night by about 26 minutes. The share of time in bed actually spent asleep went up by about 10 percentage points.
Better still, these gains seemed to hold up after therapy ended. Stopping a sleeping pill after long-term use tends to do the opposite: the WOREL guideline warns of rebound insomnia.
What does CBT-I look like in practice?
A program usually runs to a handful of sessions, one to two weeks apart: four in the Australian trial above, six in a US trial. That US trial found CBT-I by video worked as well as in-person sessions, and the European guideline also endorses digital programs.
First: a review of how you sleep, an explanation of how the therapy works, and your sleep diary, which you fill in every morning.
Next: sleep restriction and stimulus control. This is often the hardest stretch: you may sleep less at first so you can sleep better later.
Then: working on your thoughts and beliefs about sleep, along with sleep hygiene.
Finally: locking in your progress, learning how to handle a bad patch, and leaving with a plan for the future.
What does it cost in Belgium?
If you see a clinical psychologist who belongs to a mental health network with a NIHDI (INAMI/RIZIV) convention, your first individual session is free. After that, you pay €11 per session, or €4 if you qualify for increased reimbursement (BIM). Up to age 23, you pay nothing. First-line psychological support doesn't require a referral, and it covers up to 8 individual sessions per 12-month period.
So eight sessions cost you €77 out of pocket (7 × €11), or €28 with increased reimbursement. Some health insurance funds reimburse part of that through their supplementary coverage. Not every psychologist in the network is trained in CBT-I, so ask when you book.
More on reimbursement
TCCI.beFR breaks these reimbursements down fund by fund and explains the conditions of the NIHDI network.
Finding a CBT-I therapist in Belgium
TCCI.be, another free website created by Andy Leleux, lists psychologists and therapists trained in CBT-I in French-speaking Belgium. Practitioners sign up themselves, so the list isn't exhaustive. The site also has questionnaires (including the Insomnia Severity Index, or ISI), a sleep diary and guides to each step of the therapy. It's available in French only.
Visit TCCI.be →FRFrequently asked questions
Sources
- Zhang Y, et al. Worldwide and regional prevalence rates of co-occurrence of insomnia and insomnia symptoms with obstructive sleep apnea: a systematic review and meta-analysis. Sleep Med Rev. 2019;45:1-17.
- Trauer JM, et al. Cognitive Behavioral Therapy for Chronic Insomnia: A Systematic Review and Meta-analysis. Ann Intern Med. 2015;163(3):191-204.
- Edinger JD, et al. Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2021;17(2):255-62.
- Riemann D, et al. The European Insomnia Guideline: An update on the diagnosis and treatment of insomnia 2023. J Sleep Res. 2023;32(6):e14035.
- Sweetman A, et al. Cognitive and behavioral therapy for insomnia increases the use of continuous positive airway pressure therapy in obstructive sleep apnea participants with comorbid insomnia: a randomized clinical trial. Sleep. 2019;42(12):zsz178.
- Arnedt JT, et al. Telemedicine versus face-to-face delivery of cognitive behavioral therapy for insomnia: a randomized controlled noninferiority trial. Sleep. 2021;44(1):zsaa136.
- Kyle SD, et al. Sleep restriction therapy for insomnia is associated with reduced objective total sleep time, increased daytime somnolence, and objectively impaired vigilance. Sleep. 2014;37(2):229-37.
- CBIP/BCFI. Summary of the revised WOREL guideline on sleep problems and insomnia in adults (June 2026). cbip.be
- CBIP/BCFI. Belgian drug formulary, chapter 10.1: hypnotics, sedatives, anxiolytics. cbip.be
- NIHDI (INAMI/RIZIV). First-line psychological care, reimbursed through mental health networks (page in French).
See also
