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A 45-year-old female with treatment-resistant insomnia and comorbid generalized anxiety disorder has been on trazodone 100 mg at bedtime for four months and completed eight sessions of cognitive behavioral therapy for insomnia. Her baseline Insomnia Severity Index (ISI) was 24 and her sleep diary showed average sleep onset latency of 75 minutes, total sleep time of 4.5 hours, and sleep efficiency of 56%. Currently, her ISI is 18, sleep onset latency is 45 minutes, total sleep time is 5.5 hours, and sleep efficiency is 68%. She reports the trazodone helps her fall asleep initially but she wakes at 2 AM and cannot return to sleep for one to two hours. She has implemented stimulus control and sleep restriction from CBT-I with moderate adherence. She consumes two cups of coffee daily, the last one at noon. She denies alcohol, uses her phone in bed for approximately 30 minutes before attempting sleep, and exercises three times weekly in the early evening. The PMHNP is evaluating the treatment response and identifying factors limiting further improvement. Which of the following best represents the appropriate evaluation?
Explanation
Evaluating treatment-resistant insomnia requires systematic identification of modifiable behavioral factors that may be limiting response before escalating pharmacotherapy. Screen use in bed violates stimulus control principles and suppresses melatonin, and moderate CBT-I adherence suggests incomplete behavioral implementation that should be optimized before concluding that the current treatment approach has failed.
Key Takeaway
Before escalating pharmacotherapy for treatment-resistant insomnia, the PMHNP should evaluate and address modifiable behavioral factors including stimulus control violations such as screen use in bed and incomplete CBT-I adherence, as these factors frequently account for limited treatment response.