Objective To describe the outcome of a patient implanted with the Vagus Nerve Stimulation (VNS) Therapy device while receiving maintenance electroconvulsive treatment (M-ECT) and to compare costs of treatment options for TRD. Background Vagus nerve stimulation was approved for use in treatment-resistant depression in July, 2005. Maintenance ECT was used for this patient before VNS implantation and for several treatments afterwards. The patient responded to ECT but the response was short-lived requiring frequent M-ECT accompanied by some memory disturbance. Design/Methods Single case report at tertiary care center; cost comparison over time. Main outcome measure was the Montgomery-Åsberg Depression Rating Scale (MADRS). Cost Analysis of Modalities- M-ECT $800 per treatment; VNS ~$3900 per year. Results ? Patient improved with VNS Therapy and was able to discontinue M-ECT. ? MADRS scores had fluctuated between 2 and 56, but, after VNS Therapy, decreased to a level consistent with remission of depression. ? Patient reported feeling as well as at any time he could remember, began an exercise program, and lost 30 pounds. During the10 months before implantation, 14 ECT treatments=$11,200 For 10 months after implantation, 7 M-ECT treatments ($5,600) plus prorated VNS Therapy ($3,250) equaled $8,850, $2,350 less than before implantation. Conclusion This patient improved with VNS Therapy and was able to discontinue M-ECT. Introducing VNS Therapy effected a cost savings over M-ECT