Friday’s CEPAC meeting in Providence was fascinating. We spent the day comparing the clinical and cost effectiveness of some common and some new treatments for people with treatment resistant depression (TRD). Between 13 and 14 million Americans experience clinical depression each year, but only about half seek treatment and only 20% of those get adequate treatment. Unfortunately about half of those who get treatment do not respond to medications. One study found that medical and disability claims from employees with TRD are more than double the costs for other employees with depression. Options for these patients used to be limited but technology has advanced in recent years. CEPAC is a New England regional public advisory group convened to consider the clinical and cost effectiveness of competing treatments. CEPAC includes clinicians, academics, patient advocates and (nonvoting) payer representatives. Friday’s discussion centered on Repetitive Transcranial Magnetic Stimulation, a new, slightly more expensive alternative to Electroconvulsive Therapy, which has been in use for over 70 years. There are some small studies with promising results suggesting rTMS may work better for some patients with fewer side effects. We discussed the impact on subpopulations, underserved populations, Medicaid and private payers, clinicians and, most importantly, patients and their families desperate for help. We reviewed evidence that everyone agreed was inadequate and conflicting. There are almost no studies that measured long term effectiveness. And then we voted.