A behavioral sleep specialist provides a framework for difficult conversations. Use this sample dialogue to improve patient outcomes.

Sleep medicine providers know that sleep disorders are highly comorbid with other medical and psychiatric conditions. For example, over 60% of patients referred for obstructive sleep apnea evaluation are obese.1 Fifty to 70% of insomnia patients suffer a comorbid psychiatric condition, such as depression or generalized anxiety.2 Many of these patients will benefit from referral for specialist consultation. Unfortunately, sleep medicine training has not adequately prepared providers to discuss mental health referrals quickly, easily, and naturally.

As one of few behavioral sleep specialists in the Mid-Atlantic region, I am often asked to offer opinions in how to manage complex patients. Frequently, these telehealth “curbside consultations” include discussions of differential diagnosis or mental health referral. Because sleep patients are highly complex, it is incumbent on us, as expert providers, to advance our language skills when discussing aspects of treatment plans that might make patients uncomfortable. Here, you will learn a simple framework to conduct these conversations, increase adherence, and improve patient-centered outcomes.

The example in the transcript involves a mental health referral. Of course, before adopting this approach, it is vital that you identify reliable mental health treatment providers to whom you can refer! If you have not already done so, take the time to identify and meet with local mental health treatment providers who can help care for your patients. Know who is in-network and not in-network. Affordable fee-for-service tele-mental health is available nationally, even in underserved areas. Some telehealth services provide patient ratings for individual providers, while others do not. Patients should be advised that finding the right interpersonal fit can take time but is worth the effort.

The same conversation framework is equally effective when discussing other potentially sensitive domains, such as obesity management or sexual health. For best results, remember that your goal is to provide expert, compassionate care because it is in the best interest of your patient.


Wickwire Process for Mental Health Referrals in Sleep Medicine

1. Stick to the facts: reflect observed behavior and use the patient’s own words.
2. Confirm explicitly your understanding of the facts.
3. Share potential clinical impressions, based only on these specific facts.
4. Avoid labels.
5. Acknowledge that you have just met the patient for the first time, and you do not presume to have a crystal ball.
6. Lower the bar: present a hypothetical referral plan, developed in collaboration with the patient.
7. Conclude with specific behavioral instructions.

The Referral Meets the Road: Sample Patient Dialogue

Provider: At this point, I think I have a pretty good understanding of your situation and what a helpful next step might be. So, I’d like to tell you what I’ve heard and ask you to confirm or correct my understanding. Would that be OK?
Patient: Yes, that would be fine.

Provider: Your main objective is to sleep through the night, which would help you feel more energetic when you wake up and throughout the day. Then that extra energy would enable you to be more effective at work, return to the gym, and be less irritable at home. You also mentioned that you would like to visit with friends more. Am I on track this far?
Patient: Yes.

Provider: Good. Now, I also heard you say that you haven’t had much fun in years. And, your primary care physician had recommended an antidepressant a while ago, even though you never tried it. Last, you mentioned that your mother might have suffered depression, even though mental health was never really discussed in your family. Did I hear you correctly?
Patient: Yes, I guess so.

Provider: Well, it sounds to me like you are experiencing depressed mood. Now I want to be very clear: I don’t care about labels, but I very much care about hearing you correctly. Are we on the same page?


Emerson Wickwire, PhD

Patient: Maybe.

Provider: I understand your concern. Depressed mood is one of the most misunderstood terms in our language—no one knows what it means, but no one wants to have it! What I heard you say was that you are experiencing loss of pleasure, which is one of the key symptoms of depressed mood. And the fact that your primary care doctor, who knows you much better than I do, had suggested a depression medication in the past, is important. That is someone who knows you well. So, if I’m hearing you correctly, and I believe that I am, it’s important we keep this possibility in mind. Because if depression is a piece of the puzzle, we need to know that. Otherwise you won’t feel your best, and sleep through the night, which is why you are here. Does that make sense?
Patient: I guess so.

Provider: Good. Let me ask you another question: if you and I together were to decide that it might be helpful to meet with a specialist, whom I would recommend, is that something you would be open to? This is not about a long-term commitment, just meeting once and then the two of you can decide if it makes sense to move forward?
Patient: OK.

Provider: Great, I think this plan is very much in your best interests. Here is how I suggest we proceed…


Many sleep patients suffer a comorbid mental health condition that will benefit from specialty referral, for either counseling and/or psychiatric consultation. Yet discussing mental health consultation or treatment options is not a topic well addressed in medical school or sleep medicine training. Keep your patients’ best interest in mind, and rehearse this simple framework. You will improve at guiding your patients to the care they need. Your workflow and efficiency will improve. And your patients and their loved ones will thank you for it.

Emerson M. Wickwire, PhD, is director of the Insomnia Program and associate professor of Psychiatry and Medicine at the University of Maryland School of Medicine.

1. Punjabi NM. The epidemiology of adult obstructive sleep apnea. Proc Am Thorac Soc. 2008 Feb 15;5(2):136-43.
2. Stepanski EJ, Rybarczyk B. Emerging research on the treatment and etiology of secondary or comorbid insomnia. Sleep Med Rev. 2006 Feb 1;10(1):7-18.