Management of residual excessive daytime sleepiness in depression: An AFPBN consensus using the nominal group technique.

BACKGROUND: Excessive daytime sleepiness and broader hypersomnolence symptoms may persist despite improvement of core depressive symptoms, yet no specific clinical framework currently guides their assessment and management in mood disorders. This work aimed to establish a national expert consensus on the definition, assessment, management and follow-up of residual excessive daytime sleepiness associated with depression (rEDS-dep). METHODS: A nominal group consensus process was conducted from September 2025 to April 2026. A Steering Committee comprised eleven French experts with clinical and scientific expertise in psychiatry, neurology, pulmonology and sleep medicine. After a comprehensive literature review, the experts anonymously generated statements covering four domains: definition, clinical assessment, management and follow-up. Statements were discussed during two collective meetings, then rated anonymously on a 9-point Likert scale. Strong consensus was defined as more than 75% of scores≥7 combined with a median score≥8; good consensus was defined when only one of these criteria was met. Statements not reaching good/strong consensus or requiring clarification were revised and submitted to a second round of voting. RESULTS: The initial nominal group phase produced 70 statements. After two voting rounds, 48 statements were retained: 35 (73%) reached strong consensus, one (2%) reached good consensus and 12 (25%) did not reach consensus. Experts agreed on a pragmatic definition of rEDS-dep as a specific clinical syndrome characterized by a persistent alteration of arousal, associated with a significant distress and/or disability (functional impairment), and increased risk of depressive relapse and/or disability. This diagnosis is made after excluding other better possible explanations: persisting depressive symptoms, psychiatric, other medical cause, iatrogenic, or psychotropic substance-related causes, or causes related to another sleep disorder. Consensus supported a multidimensional definition including excessive daytime sleepiness, daytime drowsiness, prolonged sleep duration, involuntary naps, and/or sleep inertia, persisting daily or almost daily for more than three months despite adequate treatment and improvement of core depressive symptoms. Assessment should integrate symptom frequency and severity, related distress and/or disability, sleep and circadian behaviours, comorbidities, psychotropic exposure, sleepiness related accident risk, sleep diary, actigraphy when indicated, and self-report measures such as the Hypersomnia Severity Index (HSI) questionnaire. First-line management should prioritize reassessment of psychotropic treatments, reduction of sedative co-medications when appropriate, patient information on sleep and circadian behaviours and lifestyle habits, specific circadian interventions including morning light therapy, and occupational adaptations. Wake-promoting agents may be considered only as second-line options in selected patients with persistent distress and/or disability, or sleepiness related accident risk, in coordination with the treating psychiatrist and with regular monitoring of mood, sleep and adverse effects. Follow-up should be provided though a multidisciplinary approach involving the psychiatrist, general practitioner, and sleep specialist, with regular reassessment of hypersomnolence, depressive symptoms, comorbidities, sleepiness related accident risk and the ongoing need for wake-promoting treatment. CONCLUSIONS: This national consensus provides the first structured clinical framework for rEDS-dep. It supports recognition of rEDS-dep as a multidimensional syndrome requiring dedicated assessment, stepwise management and coordinated follow-up, while highlighting the need for observational, pathophysiological and interventional studies.