An fMRI Phenotype of Reward in Effort Expenditure in the VTA and Dorsal Raphe: A Longitudinal Study of Depression under Escitalopram Treatment

Anhedonia and motivational impairment are central features of major depressive disorder, yet the neural processes linking reward information to sustained goal-directed behaviour remain insufficiently understood. Using functional magnetic resonance imaging, we examined representations of reward levels during sustained effort expenditure (a construct in the RDoc framework) as a distinct component of reward processing in depressive patients under escitalopram treatment. Twenty-eight unmedicated patients with a current depressive episode and forty-three healthy control participants underwent fMRI scanning at two time points three weeks apart; patients started escitalopram immediately after the first measurement. Across participants, sustained effort expenditure engaged midbrain reward circuitry (ventral tegmental area, VTA), even in the absence of immediate reinforcement. A targeted analysis also revealed changes in activity of the dorsal raphe nucleus (DRN) in patients. Increases in VTA activity were associated with improvements in clinician-rated depressive symptoms, whereas self-reported anhedonia remained unchanged. By isolating neural mechanisms supporting sustained goal-directed behaviour, the study identifies novel and clinically relevant imaging phenotypes of reward processing and a potential pathway of escitalopram treatment in depression.