International Women’s Day Blog: Women’s Mental Health, Conventional Treatment Limitations & The Role of TMS

Introduction, Epidemiology & Aetiology

As we approach International Women’s Day, there is an opportunity not only to recognise the social, economic, and political achievements of women, but also to reflect on areas of public health concerns such as women’s mental health.

Women are more likely than men to exhibit internalising disorders such as depression and anxiety (Salk et al., 2017). Global estimates indicate higher prevalence of Major Depressive Disorder (MDD) (5.1% vs. 3.6%) and anxiety disorders (4.6% vs. 3.6%) in women compared with men (McKeever et al., 2017; Christiansen, 2015; World Health Organisation, 2017). These gender differences typically emerge during adolescence and persist across the lifespan (Salk et al., 2017; Auberach et al., 2018).

The aetiology of these disparities is multifactorial. Biologically, hormonal fluctuations across the female lifespan, particularly during puberty, the perinatal period, and the menopausal transition are associated with increased risk for mood and anxiety disorders (Li & Graham, 2017; Albert, 2015). Oestrogen and progesterone, key female sex hormones, promote neuroplasticity, regulate stress responses, support serotonin function and increase brain derived neurotrophic factor (BDNF). Consequently, periods characterised by significant hormonal fluctuations represent windows of increased vulnerability for mental health difficulties in women (Di Benedetto et al., 2024).

Psychosocial factors also contribute substantially to these disparities. Women are disproportionately exposed to certain stressors, such as care giving demands and gender-based violence (Di Benedetto et al., 2024). Such social experiences play a major role and often interact with biological mechanisms in shaping women’s mental health outcomes (Di Benedetto et al., 2024).

Taken together, evidence supports a biopsychosocial framework in observed gender differences in internalising psychopathology.

Limitations of Conventional Treatment Approaches

The 2022 National Institute for Health and Care Excellence (NICE) recommends Cognitive Behavioural Therapy as a first line treatment for depression, with antidepressant (AD) medication considered for more moderate to severe cases (NICE, 2022).

For generalised anxiety disorders (GAD), NICE 2011 guidelines recommend low intensity psychological interventions such as guided self-help as first line treatment, with full CBT and/or AD recommended for more moderate to severe presentations.

Meta – analyses indicates that CBT is moderately efficacious for GAD when compared to a placebo (Carpenter et al., 2018). While AD have generally been proven to be slightly more efficacious than CBT in MDD (Boschloo et al., 2019; Weitz et al., 2015).

However, while AD effectiveness in MDD has been found to be more effective than a placebo, effect sizes are small to moderate (Cipriani et al., 2018). Similarly, meta – analyses of AD and benzodiazepines in the treatment of GAD found that overall effect sizes were small to moderate in comparison to placebos (Gomez et al., 2018).

Additionally, despite guideline recommendations favouring psychological therapies as first – line treatment, pharmacological interventions are more frequently used in practice, particularly in women (Perlis et al., 2026).

Taken together, the evidence of both psychological and pharmacological interventions can be beneficial however their overall effectiveness remains modest.

In, MDD, treatment resistance depression (TRD) is commonly defined as MDD that does not respond to at least two AD trials of adequate dose and duration (Rush et al., 2006). While it is not yet established whether sex is a risk factor for TRD (Lahteenvuo et al., 2022), it remains well known that women are affected at a higher rate than men with depression and are more likely to be prescribed AD (Kuehner, 2017). Consequently, women would be expected to represent majority of the TRD population (McIntyre et al., 2023).

A similar construct exists in anxiety disorders known as treatment resistant GAD (TRGAD). This construct however lacks standardised diagnostic criteria and epidemiological data (Bokma et al., 2019). Given the higher prevalence of anxiety disorders in women, further research is required to clarify specific gender differences in treatment resistant anxiety disorders.

Women may also face gender specific treatment considerations regarding AD usage. AD discontinuation during pregnancy is common (95%) (Noh et al., 2022), which is largely due to conflicting research regarding AD usage during pregnancy and foetal outcomes. While some research associates in utero AD exposure with outcomes such as low gestational age and preterm birth (Fitton et al., 2019), others suggest minimal risk to foetal health (Lee et al., 2025). Additionally, some studies suggest that both untreated depression and AD use during pregnancy have been associated with adverse maternal and child outcomes (Ilbanez et al., 2012), further complicating pharmacological treatment decisions.

Overall, the modest efficacy of conventional treatments, treatment resistance and the complex pharmacological consideration for pregnant women, underscores the need for additional evidence-based option in women’s mental health.

The role of TMS in Women’s Mental Health

Repetitive transcranial magnetic stimulation (rTMS)  is a non-invasive, NICE-approved neuromodulation treatment (Dalhuisen et al., 2022). It is established as an effective intervention for MDD, particularly in TRD cases. Meta - analytic evidence demonstrates that rTMS is significantly effective in individuals with TRD showing meaningful improvements in both response and remission outcomes (Vida et al., 2023).

Emerging evidence also supports the use of rTMS for anxiety disorders including GAD. A recent study has found rTMS improved symptoms of anxiety alongside depression in GAD (Cox et al., 2022).

In the context of women’s mental health, firstly where prevalence rates for MDD and anxiety disorders are higher rTMS presents a promising evidence-based intervention.

Secondly, where pharmacological considerations to treatment for pregnant women can be complex, rTMS is a non–pharmacological treatment option. Meta – analyses of all available literature regarding rTMS administration across all pregnancy trimesters have provided no evidence that TMS has adverse effects to foetus (Pridmore et al., 2021). A follow up study of children of mothers who received rTMS whilst pregnant also found no problems with motor or cognitive development (Eryilmaz et al., 2015).

Finally, sex has been identified as a potential factor influencing outcome of rTMS. Women tend to show higher response and remission rates to TMS with three biological factors proposed to explain this gender difference. Anatomical differences such as shorter scalp to prefrontal cortex distance in women may result in greater effective cortical stimulation. Structural differences including variations in cortical folding and frontal grey matter volume may influence how stimulation is distributed, and hormonal fluctuations particularly in oestradiol and progesterone can modulate cortical excitability (Hanlon & McCalley, 2022).

Overall, rTMS represents as a promising evidence-based option in women’s mental health, addressing several limitations associated with conventional treatment options.

Conclusion

Women experience higher rates of depression and anxiety across the lifespan. While CBT and pharmacotherapy remain first – line treatments, efficacy is modest, pregnant women face complex treatment consideration and treatment resistance is common. In this context, evidence-based interventions such as rTMS represents an important expansion of treatment options in women’s mental health.

If you would like further information about Transcranial Magnetic Stimulation (TMS) Treatment, please do contact Smart TMS and we would be happy to help you explore your options.

Written by Niamh, our Smart TMS Dublin practitioner

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