Light therapy as an add-on to standard care for perinatal depression: a 7-month follow-up randomized controlled study

EMANUELA BIANCIARDI1, IRENE SFERRA1, GIULIA CASTELLANI1, CAROLINA PINCI1, ELICIO MARINUCCI1, ILARIA ADULTI1, ROSSELLA MAttea QUINTO2, CINZIA NIOLU1

1Psychiatric Chair, Department of Systems Medicine, University of Rome Tor Vergata, Italy; 2Department of Human Sciences, European University of Rome, Italy.

Summary. Introduction. Many women with perinatal depression (PND) do not respond adequately to treatment, and perinatal insomnia remains particularly challenging to manage. The aim of this study was to evaluate the efficacy of light therapy (LT) as an adjunctive treatment to standard care in reducing symptoms of PND and sleep disturbances. Materials and methods. Outcomes were compared with a control group of women with PND who received standard care alone. A final sample of 15 women (7 in the LT group and 8 in the non-LT group) was recruited at the “SOS MAMMA” clinic at the University of Rome “Tor Vergata.” Participants in the LT group received 30 minutes of light therapy daily for five consecutive weeks. We performed a baseline clinical assessment, and the following psychometric instruments were administered from the T0, weekly for five weeks (T1-T5), after one months (T6): Edinburgh Postnatal Depression Scale (EPDS), Pittsburgh Sleep Quality Index (PSQI), Beck Depression Inventory-II (BDI-II), Hamilton Depression Rating Scale (HAM-D). LT group underwent a follow-up six months later (T7). Results. The repeated measures ANOVA showed statistically significant Time × Group interaction effects of all psychopathological outcomes. LT-group showed greater improvements of depressive symptoms (BDI-II: Wilks’ λ= .281, F= 3.42, η2= .719, p= .056; HAM-D: Wilks’ λ= .290, F= 3.27, η2= .710, p= .062; EPDS: Wilks’ λ= .134, F= 8.61, η2= .866, p= .004) and sleep quality (PSQI: Wilks’ λ= .302, F= 3.07, η2= .698, p= .072) compared to the non-LT group. In the LT-group, the paired-sample t-tests comparing T6 with T7 showed improvements of BDI-II (t, 6= 3.81; Cohen’s d= 1.44; p= .009) and PSQI (t, 6= 3.10; Cohen’s d= 1.17; p= .021), indicating that the effectiveness was maintained over time. Conclusions. Light therapy proved effective as an augmentation treatment in women with perinatal depression, demonstrating sustained efficacy over time and strategic tolerability. We propose that LT is a valuable intervention that targets difficult-to-treat symptoms such as insomnia, and may allow for the use of lower doses of antidepressants – reducing concerns about potential adverse effects on the offspring.

Key words. Gender medicine, insomnia, light therapy, major depressive disorder, perinatal depression, sleep disorders, women mental health.

Terapia della luce come terapia aggiuntiva alla cura standard per la depressione perinatale: uno studio randomizzato controllato di follow-up di 7 mesi.

Riassunto. Introduzione. Molte donne con depressione perinatale (PND) non rispondono alle terapie e l’insonnia è un sintomo difficile da trattare. Scopo dello studio è valutare l’efficacia della Light therapy (LT) come terapia aggiuntiva alle cure standard, sui sintomi depressivi e sui disturbi del sonno. Materiali e metodi. Abbiamo reclutato un campione finale di 15 donne, 7 donne sottoposte a LT e cure standard e 8 donne come gruppo di controllo che ha seguito le cure standard, dallo sportello “SOS MAMMA” dell’Università di Roma “Tor Vergata”. Il gruppo sperimentale ha effettuato un ciclo di cinque settimane di LT, con sessioni di 30 minuti al giorno. È stata effettuata la valutazione psicopatologica al momento del reclutamento e abbiamo somministrato test psicometrici ogni settimana per cinque settimane (T0-T5), dopo un mese (T6) e nel gruppo sperimentale, dopo altri sei mesi (T6). I test erano: l’Edinburgh Postnatal Depression Scale (EPDS), il Pittsburgh Sleep Quality Index (PSQI), il Beck Depression Inventory-II (BDI-II), la Hamilton Depression Rating Scale (HAM-D). L’ANOVA a misure ripetute ha mostrato effetti statisticamente significativi dell’interazione Tempo × Gruppo di tutte le misure psicometriche. Il gruppo sottoposto a LT ha mostrato miglioramenti più significativi dei sintomi depressivi (BDI-II: λ di Wilks= .281, F= 3.42, η2= .719, p= .056; HAM-D: λ di Wilks= .290, F= 3.27, η2= .710, p= .062; EPDS: λ di Wilks= .134, F= 8.61, η2= .866, p= .004) e della qualità del sonno (PSQI: λ di Wilks= .302, F= 3.07, η2= .698, p= .072), rispetto al gruppo di controllo. Risultati. Nel gruppo sottoposto a LT, il t-test per campioni appaiati per il confronto tra T6 e T7 ha mostrato miglioramenti della BDI-II (t, 6= 3,81; d di Cohen= 1,44; p= 0,009) e del PSQI (t, 6= 3,10; d di Cohen= 1,17; p= 0,021), dimostrando che l’efficacia sui sintomi depressivi e sull’insonnia si mantiene nel tempo. Conclusioni. Nelle donne con depressione perinatale, la LT è una terapia aggiuntiva efficace nel breve e nel lungo termine, senza effetti collaterali. Suggeriamo di utilizzare la LT in modo strategico sui sintomi invalidanti e difficili da trattare come l’insonnia. Inoltre, l’efficacia della LT potrebbe consentire una riduzione della terapia antidepressiva, i cui temuti effetti sulla prole compromettono l’aderenza delle donne ai percorsi terapeutici e l’alleanza terapeutica.

Parole chiave. Depressione perinatale, light therapy, salute mentale femminile, medicina di genere, depressione maggiore, disturbi del sonno, insonnia.

Introduction

Perinatal depression (PND) is one of the most common and concerning complications of pregnancy, with potentially serious consequences for mothers, newborns, and co-parents1. Although there is some variability in the prevalence among high and low income countries, it affects up to 25-35% of women in the perinatal period, and antenatal and postpartum onset are reported in 10-15% and 10-16.4% of pregnancies, respectively2,3. The greatest risk of severe symptoms and hospitalization occurs within the first month after delivery and suicide is among the leading causes of maternal death, accounting for 10-20% of all peripartum maternal deaths4. Approximately 50% of postpartum depressive episodes begin before delivery and symptoms can develop up to a year after giving birth5.

The clinical presentation can be heterogeneous, with symptoms such as insomnia and fatigue often misinterpreted as typical aspects of pregnancy or attributed to the demands of caring for a newborn, and therefore potentially underestimated. Furthermore, shame, guilt, and stigma can prevent women from seeking specialized help, resulting in a so-called treatment cascade for PND, meaning only a small percentage of women receive adequate treatment6. Many barriers prevent women from seeking psychiatric help, including concerns about the potential side effects of medications on the baby and fears that disclosing a mental health condition could lead to social services intervening or even removing the child7-9.

However, untreated depression is associated with short- and long-term negative consequences for both mother and child10 but pharmacotherapy is not the only option. The National Institute for Health and Care Excellence (NICE) guideline for the management of PND, recommended psychotherapy for mild symptoms and pharmacotherapy plus psychotherapy for moderate to severe symptoms11. The most recent Canadian guideline included light therapy (LT) as a first-line lifestyle intervention for the treatment of postpartum depression12.

Light therapy is a non-pharmacological intervention originally developed for the treatment of seasonal affective disorder. It involves exposure to a light-emitting device that delivers a specific intensity of light, stimulating retinal ganglion cells and thereby improving mood and sleep. This retinal stimulation activates the suprachiasmatic nucleus of the hypothalamus – the body’s master circadian clock – as well as the lateral habenula, a key structure within the limbic system. By regulating circadian rhythms, light therapy exerts antidepressant effects through multiple mechanisms, including modulation of hormone secretion and serotonergic pathways, ultimately enhancing energy levels, concentration, and attention13,14. During both pregnancy and the postpartum period, women commonly experience sleep disturbances, resulting from a complex interplay of hormonal, physical, and lifestyle changes characteristic of this stage15,16. Hence, in the perinatal period, insomnia can trigger or worsen depression and interfere with the mother-child relationship17. A systematic review and meta-analysis of eight studies support the effectiveness of LT for depression in the perinatal period without reporting adverse effect18. In summary, light therapy has been shown to be quite effective in perinatal depression, but it is unclear whether the effects are sustained over time. Moreover, the use combination of LT and antidepressant therapy was found to be more effective compared to pharmacological therapy alone in major depressive episodes19.

We therefore hypothesized that, similar to major depression, light therapy augmentation during the peripartum period could be more effective than standard therapy alone.

The aim of the study was to test the effectiveness of LT as an add-on treatment to standard care in women with peripartum depression, comparing outcomes with those women receiving standard care alone. Our primary focus was the remission of depressive symptoms and co-occurring insomnia. Further, we evaluated the long-term efficacy of LT at 7-months follow-up.

Materials and methods

We recruited our sample of women at the “SOS MAMMA” clinic at the University of Rome, “Tor Vergata” in Italy which is an outpatient service dedicated to the treatment of mental disorders in the perinatal period.

Eligible participants were women aged 18 or older, diagnosed with perinatal depression by a perinatal specialist based on DSM-5-TR criteria, and presenting with an Edinburgh Postnatal Depression Scale (EPDS) score of 12 or above.

The women included in the study were pregnant or in the “fourth trimester”, within three months of giving birth20.

Exclusion criteria were lifetime history of bipolar disorder and current and past retinal diseases.

The study complied with the APA’s ethical standards in the treatment of participants, following the Ethical Principles for Medical Research Involving Human Subjects (Declaration of Helsinki). The study was approved by the Institutional Ethics Committee of the University of Rome “Tor Vergata” on March 14, 2018. All participants provided written informed consent.

Twenty-six women were enrolled, 13 of whom were randomly assigned to the light therapy plus standard care group (LT group), while the other 13 were assigned to the standard care group (non-LT group). Of the initial sample, 15 women (7 in the LT group and 8 in the non-LT group) completed all scheduled assessments and were included in the final analysis.

The non-LT group received standard care, consisting of antidepressants and/or psychotherapy, in accordance with current scientific and clinical best practice guidelines.

In this group, four patients were taking SSRI antidepressants – two sertraline and two escitalopram.

The psychotherapy consisted of eight sessions of brief strategic therapy, specifically focused on the peripartum period.

The LT group received standard care, plus the LT treatment.

In this group, three patients were treated with the SSRI antidepressant escitalopram.

Women in the LT group underwent light therapy at home; we provided them with the device (Philips®, goLITE BLU EnergyLight HF3320/01). The women were instructed on how to perform the therapy, exposing themselves to the light emitted by the lamp (10,000 Lux) at a distance of 40-50 cm. Participants performed 30 minutes of therapy per day for five consecutive weeks, between 7 and 9 a.m., within 30 minutes of waking up.

Clinical visits and psychometric assessments were performed at the University of Rome “Tor Vergata” Hospital, with several follow-ups scheduled from T0 to T7. T0 corresponds to the baseline assessment, T0-T5 are weekly assessments, T6 was scheduled one month after T5, and T7 six months after T6. The assessment was conducted by a psychiatry resident with perinatal training, under the supervision of a specialist psychiatrist.

All women underwent an initial psychiatric interview to collect socio-demographic, medical, and psychiatric information, and psychometric tests, administered weekly for 5 weeks (T0-T5) and at one-month follow-up (T6). Women in the LT group underwent a further psychometric evaluation after six months (T7).

The Italian version of the following psychometrics was administered:

• The Edinburgh Postnatal Depression Scale (EPDS) is a 10-items self-reported tool widely used for the screening of perinatal depression. Participants are asking to rate their symptoms over the past 7 days. Each item is scored from 0 to 3, with higher scores indicates more severe depression. We used a score of 12 or higher has a threshold for clinically significant symptoms21,22.

• Pittsburgh Sleep Quality Index (PSQI) is measure of sleep quality and disturbances It consists of 19 items completed by the subject plus 5 items to be answered by the bedpartner that are not included in the total score. The 19 items are grouped into seven categories: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medications, and daytime dysfunctions. The sum of the seven component scores gives an overall PSQI score, with higher scores indicating poorer sleep quality23,24.

• The Beck Depression Inventory-II (BDI-II) is a self-report questionnaire used for the assessment of depressive symptoms in clinical and non-clinical populations. It consists of 21 items (scored on a 0-3 Likert scale) and their sum describes different levels of symptom severity (0 to 13: no depressive symptoms; 14 to 19: mild depression; 20 to 29: moderate depression; 30 to 63: severe depression). Respondents choose the statement that best reflects their experience in the past two weeks. Adequate internal consistency and evidence of convergent and discriminant validity were reported in the perinatal women25,26.

• The Hamilton Depression Rating Scale (HAM-D) is a clinician-administered depression assessment scale. It refers to the last seven days and assesses the severity of depression and monitors treatment progress. We used the 17-item version, with higher scores indicating more severe symptom27,28.

Data analysis

The normality of the data distribution was assessed through skewness and kurtosis indices, supplemented by the Shapiro-Wilk and Kolmogorov-Smirnov tests, and by visual inspection of Q-Q plots. These analyses confirmed that the data met the assumptions of normality, supporting the use of parametric statistical methods. Socio-demographic features were described using frequencies and percentages for categorical variables and means with standard deviations for continuous variables (i.e., age). Between-group differences at baseline were examined using independent samples t-tests for continuous measures and contingency tables chi-square tests (χ2) for categorical variables.

To evaluate changes over time and group differences, repeated measures analyses of variance (ANOVAs) were performed, with Time (seven levels; i.e., baseline, week 1-5, one-month follow-up) as the within-subjects factor and Group (Treatment Group vs. Active Control Group) as the between-subjects factor. Mauchly’s test was used to assess the assumption of sphericity. Multivariate tests (e.g., Wilks’ Lambda) were also considered to ensure the robustness of the findings, particularly given the small sample size. Effect sizes were reported using partial eta-squared (η2) to quantify the magnitude of significant effects.

To investigate the maintenance of treatment effects over time, additional analyses were conducted within the experimental group – the only group assessed at the 7-months follow-up (T7). A series of paired-sample t-tests were carried out, one for each dependent variable (i.e., BDI, HAM-D, EPD, and PSQI), comparing scores at the one-month follow-up (T6) with those at the six-month follow-up (T7). Cohen’s d was computed for each comparison to estimate the effect size. All statistical analyses were conducted using SPSS for Windows, version 26.0, and a significance level of p< .10 was adopted for all tests.

Results

Table 1 presents the baseline sociodemographic and psychopathological characteristics of participants in the different groups. The groups were comparable on all demographic variables, except age (t(13)= -2.10, p< 0.060), with the treatment group being the youngest. No baseline differences emerged of psychopathological measures (i.e., BDI-II, HAM-D, PSQI, EPDS), indicating equivalence at the T0.




None of the women reported any of the specified side effects – eye irritation, eyestrain, headache, or nausea – nor did they report any other adverse effects.

The repeated measures ANOVA (table 2) revealed statistically significant Time × Group interaction effects of all psychopathological outcomes, suggesting that the intervention had a differential impact over time. Participants of the LT-group showed significantly greater improvements of depressive symptoms (BDI-II: Wilks’ λ= .281, F= 3.42, η2= .719, p= .056; HAM-D: Wilks’ λ= .290, F= 3.27, η2= .710, p= .062; EPDS: Wilks’ λ= .134, F= 8.61, η2= .866, p= .004) and sleep quality (PSQI: Wilks’ λ= .302, F= 3.07, η2= .698, p= .072) compared to the non-LT group.




Follow-up analyses were conducted by comparing scores at one-month follow-up (T6) and seven-months follow-up (T7) within the LT-group to assess the persistence of change from one to seven-months post-intervention. Paired-sample t-tests revealed statistically significant improvements in BDI-II (t, 6= 3.81; Cohen’s d= 1.44; p= .009) and PSQI (t, 6= 3.10; Cohen’s d= 1.17; p= .021), indicating that the effectiveness of LT was maintained over time (figure 1).




Discussion

The main result of this study is that the add-on of light therapy to standard of care was more effective than standard of care alone in improving depressive symptoms and sleep disturbance in women with perinatal depression. Further, we provided evidence that the improvement of depression and quality of sleep was sustained in the long term, after seven months of treatment.

We emphasize that baseline depressive symptoms were moderate to severe, as reported by psychometric scores, in both the LT and non-LT therapy groups. Given this, the use of an additional therapeutic tool is particularly important, as light therapy enhances the effectiveness of standard treatments and can treat symptoms that do not respond to other treatments or become subthreshold and persistent.

To date, there are limited evidence regarding the effectiveness of antidepressants and psychotherapy on perinatal depression29 and, to our knowledge, no studies have documented which difficult-to-treat PND symptoms remain after treatment. However, according to studies on depression, among the most difficult-to-treat symptoms are fatigue, sleep disturbances, and cognitive symptoms, which continue to cause significant distress despite usual therapeutic efforts30-33. These above symptoms are known to be affected by the light therapy34,35.

As we have shown, light therapy has proven to be a useful non-pharmacological approach for the treatment of sleep disturbances. Perinatal insomnia is a public health problem, with more than half of pregnant women meeting diagnostic criteria for insomnia disorders or experiencing debilitating insomnia symptoms36. Perinatal depression is more common and severe in women with insomnia than in those without37. Notably, insomnia symptoms persist even in the postnatal period, and approximately half of women complain of insomnia up to two years after childbirth38, while many do not experience complete recovery until six years after giving birth39. Insomnia is a depressive symptom but is also an etiological factor of perinatal depression. Nocturnal cognitive arousal, characterized by persistent thoughts about perinatal concerns while trying to fall asleep, disrupts sleep. Consequently, staying awake at night increases the time for further cognitive arousal40. In addition, insomnia was associated with poorer physical health and risk of obesity in pregnancy41,42. Given the high prevalence of insomnia and depression in the perinatal period and the literature demonstrating that insomnia is a risk factor for depression, we support the data identifying light therapy as a promising therapeutic approach.

Another merit of this study is that it provides evidence of the efficacy of a treatment with exceptional tolerability and safety for both mother and child. Consistent with literature, we did not record any side effects and light therapy did not negatively interfere with other pharmacotherapies43. Nearly all pregnant or breastfeeding women are very concerned about the potential adverse effects of drug therapies on their offspring, which prevents them from seeking specialist care44. Therefore, light therapy represents a valuable therapeutic option, as it alleviates symptoms and encourages the woman to follow the therapeutic path, consequently improving the doctor-patient relationship which is essential and reducing dropout rate45-48.

Furthermore, we believe that light therapy may be useful in the early stages of pregnancy by helping the doctor prescribe a lower dose of antidepressants during this delicate embryonic phase and as an interim measure when symptoms are mild, postponing pharmacological interventions, when necessary.

Finally, another important finding is the sustained efficacy of adjunctive light therapy over time, as documented throughout the follow-up period. Seven months after the end of the light therapy cycle, women reported an improvement in depressive symptoms and insomnia, even greater than that observed in the first month of follow-up. Long-term remission of symptoms is critical in the perinatal period both during pregnancy and in the postpartum months. Maternal mental health is known to affect the brain and physical development of the fetus from conception49,50. From this perspective, long-lasting maternal well-being during pregnancy protects offspring from the negative consequences of depression, which include cognitive, emotional, and behavioral deficits in childhood and adulthood.

After delivery, the mother-child relationship decisively influences the child’s future interpersonal behavior, shaping the child’s expectations and beliefs about others and how to interact with them51.

Thus, achieving remission of depression in women inhibit transgenerational transmission of the disease to the offspring.

In summary, our results highlighted that adjunctive treatment with light therapy is effective, noninvasive, affordable, easily accessible, and safe for both mother and child.

We recognize limitations of our study. The small sample size may introduce potential bias and limit the generalizability of the findings. We recruited a small population of women without distinguishing between those pregnant and those in the postpartum period, which did not allow us to evaluate the effectiveness of LT in the two periods nor to explore the differences between those taking antidepressants and those submitted to psychotherapy. In fact, of the 26 women recruited, only 15 completed the protocol, since light therapy is a long process that requires a certain degree of cooperation and self-care from the women, which can be complicated if they suffer from depression. Another limitation of the study is that light therapy was self-administered at home without direct supervision, which may have affected adherence and treatment consistency.

However, at each follow-up point, assessments were conducted in person by a psychiatrist specialized in perinatal mental health, and we carried out an extended follow-up period, allowing comparison with previous studies. Another strong point is that we compared the results over time with a control group submitted only to the standard care.

In conclusion, our findings demonstrate that light therapy provides significant benefits for women, improving both depressive symptoms and insomnia in the short term and maintaining these improvements over time.

Conclusions

Light therapy is an effective augmentation treatment for women with perinatal depression, demonstrating sustained remission over the follow-up period and offering strategic tolerability for a vulnerable population such as the mother-infant dyad. Successful implementation of care for perinatal depression requires a therapeutic approach that addresses the most insidious and treatment-resistant symptoms, ensures safety for both mother and child, and fosters a strong therapeutic relationship.

Author contributions: E.B. and CN designed the study. E.B wrote the manuscript, C.P., I.S., G.C. and E.M collected data and performed the assessments. R.M.Q. performed the statistical analysis and wrote the results. All authors revised the manuscript and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work were appropriately investigated and resolved. All authors have read and agreed to the published version of the manuscript.

Conflicts of interest: the authors declare no conflict of interest.

Funding: this research received no external funding.

Institutional review board statement: the study was performed in accordance with the Helsinki declaration standards and was approved by the Institutional Ethics Review Committee of the University of Rome “Tor Vergata” on 14 March 2018.

Informed consent statement: all participants provided written and informed consent.

Data availability statement: the dataset is available from the corresponding author upon reasonable request.

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