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A 52-year-old female with chronic insomnia disorder has been participating in cognitive behavioral therapy for insomnia (CBT-I) for six weeks, including sleep restriction, stimulus control, and cognitive restructuring. She completed a two-week sleep diary prior to the visit. Her baseline sleep diary two months ago showed average sleep onset latency (SOL) of 55 minutes, wake after sleep onset (WASO) of 80 minutes, total sleep time (TST) of 4.8 hours, time in bed (TIB) of 8.5 hours, and sleep efficiency (SE) of 56%. Her current sleep diary shows average SOL of 18 minutes, WASO of 25 minutes, TST of 5.5 hours, TIB of 6.25 hours, and SE of 88%. She reports feeling more rested despite sleeping fewer total hours and states her daytime fatigue has improved substantially. However, she expresses concern that she is sleeping only 5.5 hours per night and worries this is insufficient for her health. She asks whether CBT-I is actually working since she is sleeping less total time than before she started treatment. The PMHNP is evaluating the treatment response based on the sleep diary data. Which of the following best represents the appropriate evaluation?
Explanation
Sleep efficiency, not total sleep time, is the primary outcome measure for CBT-I. Sleep restriction therapy intentionally reduces time in bed to consolidate sleep, and total sleep time is gradually increased through systematic sleep window extension once sleep efficiency exceeds 85%. Patients commonly express concern about reduced total sleep time during the active phase of treatment, which requires psychoeducation about the distinction between sleep quality and quantity.
Key Takeaway
When evaluating CBT-I response using sleep diary data, the PMHNP should prioritize sleep efficiency over total sleep time, recognizing that the apparent reduction in total hours reflects the expected therapeutic consolidation effect that will be followed by gradual sleep window extension.