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Calabro FJ, Parr AC, Sydnor VJ, Hetherington H, Prasad KM, Ibrahim TS, Sarpal DK, Famalette A, Verma P, Luna B. Leveraging ultra-high field (7T) MRI in psychiatric research. Neuropsychopharmacology 2024:10.1038/s41386-024-01980-6. [PMID: 39251774 DOI: 10.1038/s41386-024-01980-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 06/21/2024] [Accepted: 07/23/2024] [Indexed: 09/11/2024]
Abstract
Non-invasive brain imaging has played a critical role in establishing our understanding of the neural properties that contribute to the emergence of psychiatric disorders. However, characterizing core neurobiological mechanisms of psychiatric symptomatology requires greater structural, functional, and neurochemical specificity than is typically obtainable with standard field strength MRI acquisitions (e.g., 3T). Ultra-high field (UHF) imaging at 7 Tesla (7T) provides the opportunity to identify neurobiological systems that confer risk, determine etiology, and characterize disease progression and treatment outcomes of major mental illnesses. Increases in scanner availability, regulatory approval, and sequence availability have made the application of UHF to clinical cohorts more feasible than ever before, yet the application of UHF approaches to the study of mental health remains nascent. In this technical review, we describe core neuroimaging methodologies which benefit from UHF acquisition, including high resolution structural and functional imaging, single (1H) and multi-nuclear (e.g., 31P) MR spectroscopy, and quantitative MR techniques for assessing brain tissue iron and myelin. We discuss advantages provided by 7T MRI, including higher signal- and contrast-to-noise ratio, enhanced spatial resolution, increased test-retest reliability, and molecular and neurochemical specificity, and how these have begun to uncover mechanisms of psychiatric disorders. Finally, we consider current limitations of UHF in its application to clinical cohorts, and point to ongoing work that aims to overcome technical hurdles through the continued development of UHF hardware, software, and protocols.
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Affiliation(s)
- Finnegan J Calabro
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA.
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Ashley C Parr
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Valerie J Sydnor
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Konasale M Prasad
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
- Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Tamer S Ibrahim
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Deepak K Sarpal
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Alyssa Famalette
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Piya Verma
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Beatriz Luna
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Psychology, University of Pittsburgh, Pittsburgh, PA, USA
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Levi S, Ripamonti M, Moro AS, Cozzi A. Iron imbalance in neurodegeneration. Mol Psychiatry 2024; 29:1139-1152. [PMID: 38212377 PMCID: PMC11176077 DOI: 10.1038/s41380-023-02399-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 12/19/2023] [Accepted: 12/22/2023] [Indexed: 01/13/2024]
Abstract
Iron is an essential element for the development and functionality of the brain, and anomalies in its distribution and concentration in brain tissue have been found to be associated with the most frequent neurodegenerative diseases. When magnetic resonance techniques allowed iron quantification in vivo, it was confirmed that the alteration of brain iron homeostasis is a common feature of many neurodegenerative diseases. However, whether iron is the main actor in the neurodegenerative process, or its alteration is a consequence of the degenerative process is still an open question. Because the different iron-related pathogenic mechanisms are specific for distinctive diseases, identifying the molecular mechanisms common to the various pathologies could represent a way to clarify this complex topic. Indeed, both iron overload and iron deficiency have profound consequences on cellular functioning, and both contribute to neuronal death processes in different manners, such as promoting oxidative damage, a loss of membrane integrity, a loss of proteostasis, and mitochondrial dysfunction. In this review, with the attempt to elucidate the consequences of iron dyshomeostasis for brain health, we summarize the main pathological molecular mechanisms that couple iron and neuronal death.
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Affiliation(s)
- Sonia Levi
- Vita-Salute San Raffaele University, Milano, Italy.
- IRCCS San Raffaele Scientific Institute, Milano, Italy.
| | | | - Andrea Stefano Moro
- Vita-Salute San Raffaele University, Milano, Italy
- Department of Psychology, Sigmund Freud University, Milan, Italy
| | - Anna Cozzi
- IRCCS San Raffaele Scientific Institute, Milano, Italy
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Cabral L, Calabro FJ, Foran W, Parr AC, Ojha A, Rasmussen J, Ceschin R, Panigrahy A, Luna B. Multivariate and regional age-related change in basal ganglia iron in neonates. Cereb Cortex 2024; 34:bhad456. [PMID: 38059685 DOI: 10.1093/cercor/bhad456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 10/31/2023] [Accepted: 11/01/2023] [Indexed: 12/08/2023] Open
Abstract
In the perinatal period, reward and cognitive systems begin trajectories, influencing later psychiatric risk. The basal ganglia is important for reward and cognitive processing but early development has not been fully characterized. To assess age-related development, we used a measure of basal ganglia physiology, specifically brain tissue iron, obtained from nT2* signal in resting-state functional magnetic resonance imaging (rsfMRI), associated with dopaminergic processing. We used data from the Developing Human Connectome Project (n = 464) to assess how moving from the prenatal to the postnatal environment affects rsfMRI nT2*, modeling gestational and postnatal age separately for basal ganglia subregions in linear models. We did not find associations with tissue iron and gestational age [range: 24.29-42.29] but found positive associations with postnatal age [range:0-17.14] in the pallidum and putamen, but not the caudate. We tested if there was an interaction between preterm birth and postnatal age, finding early preterm infants (GA < 35 wk) had higher iron levels and changed less over time. To assess multivariate change, we used support vector regression to predict age from voxel-wise-nT2* maps. We could predict postnatal but not gestational age when maps were residualized for the other age term. This provides evidence subregions differentially change with postnatal experience and preterm birth may disrupt trajectories.
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Affiliation(s)
- Laura Cabral
- Department of Radiology University of Pittsburgh, Pittsburgh, PA 15224, United States
| | - Finnegan J Calabro
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA 15213, United States
- Department of Bioengineering, University of Pittsburgh, 15213, United States
| | - Will Foran
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA 15213, United States
| | - Ashley C Parr
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA 15213, United States
| | - Amar Ojha
- Center for Neuroscience, University of Pittsburgh, Pittsburgh, PA 15213, United States
- Center for the Neural Basis of Cognition, University of Pittsburgh, Pittsburgh, PA 15213, United States
| | - Jerod Rasmussen
- Development, Health and Disease Research Program, University of California, Irvine, CA 92697, United States
- Department of Pediatrics, University of California, Irvine, CA 92697, United States
| | - Rafael Ceschin
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA 15224, United States
| | - Ashok Panigrahy
- Department of Radiology University of Pittsburgh, Pittsburgh, PA 15224, United States
| | - Beatriz Luna
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA 15213, United States
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Cascone AD, Calabro F, Foran W, Larsen B, Nugiel T, Parr AC, Tervo-Clemmens B, Luna B, Cohen JR. Brain tissue iron neurophysiology and its relationship with the cognitive effects of dopaminergic modulation in children with and without ADHD. Dev Cogn Neurosci 2023; 63:101274. [PMID: 37453207 PMCID: PMC10372187 DOI: 10.1016/j.dcn.2023.101274] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 07/03/2023] [Accepted: 07/06/2023] [Indexed: 07/18/2023] Open
Abstract
Children with attention-deficit/hyperactivity disorder (ADHD) exhibit impairments in response inhibition. These impairments are ameliorated by modulating dopamine (DA) via the administration of rewards or stimulant medication like methylphenidate (MPH). It is currently unclear whether intrinsic DA availability impacts these effects of dopaminergic modulation on response inhibition. Thus, we estimated intrinsic DA availability using magnetic resonance-based assessments of basal ganglia and thalamic tissue iron in 36 medication-naïve children with ADHD and 29 typically developing (TD) children (8-12 y) who underwent fMRI scans and completed standard and rewarded go/no-go tasks. Children with ADHD additionally participated in a double-blind, randomized, placebo-controlled, crossover MPH challenge. Using linear regressions covarying for age and sex, we determined there were no group differences in brain tissue iron. We additionally found that higher putamen tissue iron was associated with worse response inhibition performance in all participants. Crucially, we observed that higher putamen and caudate tissue iron was associated with greater responsivity to MPH, as measured by improved task performance, in participants with ADHD. These results begin to clarify the role of subcortical brain tissue iron, a measure associated with intrinsic DA availability, in the cognitive effects of reward- and MPH-related dopaminergic modulation in children with ADHD and TD children.
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Affiliation(s)
- Arianna D Cascone
- Neuroscience Curriculum, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Finnegan Calabro
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA; Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - William Foran
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Bart Larsen
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Tehila Nugiel
- Carolina Institute for Developmental Disabilities, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Ashley C Parr
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Brenden Tervo-Clemmens
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Beatriz Luna
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jessica R Cohen
- Carolina Institute for Developmental Disabilities, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA; Biomedical Research Imaging Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Songco A, Patel SD, Dawes K, Rodrigues E, O'Leary C, Hitchcock C, Dalgleish T, Schweizer S. Affective working memory in depression. Emotion 2023; 23:1802-1807. [PMID: 36441997 PMCID: PMC10448741 DOI: 10.1037/emo0001130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 05/09/2022] [Accepted: 05/11/2022] [Indexed: 11/29/2022]
Abstract
Depressed individuals show a wide range of difficulties in executive functioning (including working memory), which can be a significant burden on everyday mental processes. Theoretical models of depression have proposed these difficulties to be especially pronounced in affective contexts. However, evidence investigating affective working memory (WM) capacity in depressed individuals has shown mixed results. The preregistered study used a complex span task, which has been shown to be sensitive to difficulties with WM capacity in affective relative to neutral contexts in other clinical groups, to explore affective WM capacity in clinical depression. Affective WM capacity was compared between individuals with current depression (n = 24), individuals in remission from depression (n = 25), and healthy controls (n = 30). The results showed that, overall, WM capacity was more impaired in the context of negative distractor images, relative to neutral images. Furthermore, those with a lifetime history of depression (individuals with current depression and individuals remitted from depression), performed worse on the task, compared to healthy controls. However, there was no support for the greater disruption of WM capacity in affective compared to neutral contexts in those with a lifetime history of depression. These findings' implications for current models of depression are discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
- Annabel Songco
- School of Psychology, University of New South Wales Sydney
| | - Shivam D Patel
- MRC Cognition and Brain Sciences Unit, University of Cambridge
| | - Katy Dawes
- MRC Cognition and Brain Sciences Unit, University of Cambridge
| | | | | | | | - Tim Dalgleish
- MRC Cognition and Brain Sciences Unit, University of Cambridge
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Jakary A, Lupo JM, Mackin S, Yin A, Murray D, Yang T, Mukherjee P, Larson P, Xu D, Eisendrath S, Luks T, Li Y. Evaluation of major depressive disorder using 7 Tesla phase sensitive neuroimaging before and after mindfulness-based cognitive therapy. J Affect Disord 2023; 335:383-391. [PMID: 37192691 DOI: 10.1016/j.jad.2023.05.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 04/21/2023] [Accepted: 05/12/2023] [Indexed: 05/18/2023]
Abstract
OBJECTIVE We applied 7 Tesla phase sensitive imaging to evaluate the impact of brain iron levels on depression severity and cognitive function in individuals with major depressive disorder (MDD) treated with mindfulness-based cognitive therapy (MBCT). METHODS Seventeen unmedicated MDD participants underwent MRI, evaluation of depression severity, and cognitive testing before and after receiving MBCT, compared to fourteen healthy controls (HC). Local field shift (LFS) values, measures of brain iron levels, were derived from phase images in the putamen, caudate, globus pallidus (GP), anterior cingulate cortex (ACC) and thalamus. RESULTS Compared to the HC group, the MDD group had significantly lower baseline LFS (indicative of higher iron) in the left GP and left putamen and had a higher number of subjects with impairment in a test of information processing speed. In the MDD group, lower LFS values in the left and right ACC, right putamen, right GP, and right thalamus were significantly associated with depression severity; and lower LFS in the right GP was correlated with worse performance on measures of attention. All MBCT participants experienced depression relief. MBCT treatment also significantly improved executive function and attention. MBCT participants with lower baseline LFS values in the right caudate experienced significantly greater improvement in depression severity with treatment; and those with lower LFS values in the right ACC, right caudate, and right GB at baseline performed better on measures of verbal learning and memory after MBCT. CONCLUSIONS Our study highlights the potential contribution of subtle differences in brain iron to MDD symptoms and their successful treatment.
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Affiliation(s)
- Angela Jakary
- Department of Radiology and Biomedical Imaging, UCSF, San Francisco, CA, United States of America
| | - Janine M Lupo
- Department of Radiology and Biomedical Imaging, UCSF, San Francisco, CA, United States of America
| | - Scott Mackin
- Department of Psychiatry and Behavioral Sciences, UCSF, San Francisco, CA, United States of America
| | - Audrey Yin
- Department of Radiology and Biomedical Imaging, UCSF, San Francisco, CA, United States of America
| | - Donna Murray
- Department of Psychiatry and Behavioral Sciences, UCSF, San Francisco, CA, United States of America
| | - Tony Yang
- Department of Psychiatry and Behavioral Sciences, UCSF, San Francisco, CA, United States of America
| | - Pratik Mukherjee
- Department of Radiology and Biomedical Imaging, UCSF, San Francisco, CA, United States of America
| | - Peder Larson
- Department of Radiology and Biomedical Imaging, UCSF, San Francisco, CA, United States of America
| | - Duan Xu
- Department of Radiology and Biomedical Imaging, UCSF, San Francisco, CA, United States of America
| | - Stuart Eisendrath
- Department of Psychiatry and Behavioral Sciences, UCSF, San Francisco, CA, United States of America
| | - Tracy Luks
- Department of Radiology and Biomedical Imaging, UCSF, San Francisco, CA, United States of America
| | - Yan Li
- Department of Radiology and Biomedical Imaging, UCSF, San Francisco, CA, United States of America.
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Xu B, Wei S, Yin X, Jin X, Yan S, Jia L. The relationship between childhood emotional neglect experience and depressive symptoms and prefrontal resting functional connections in college students: The mediating role of reappraisal strategy. Front Behav Neurosci 2023; 17:927389. [PMID: 36969801 PMCID: PMC10037214 DOI: 10.3389/fnbeh.2023.927389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 02/01/2023] [Indexed: 03/12/2023] Open
Abstract
Childhood emotional neglect (CEN) has a relatively high incidence rate and substantially adverse effects. Many studies have found that CEN is closely related to emotion regulation and depression symptoms. Besides, the functional activity of the prefrontal lobe may also be related to them. However, the relationships between the above variables have not been thoroughly studied. This study recruited two groups of college students, namely, those with primary CEN (neglect group) and those without childhood trauma (control group), to explore the relationships among CEN, adulthood emotion regulation, depressive symptoms, and prefrontal resting functional connections. The methods used in this study included the Childhood Trauma Questionnaire (CTQ), Emotion Regulation Questionnaire (ERQ), Beck Depression Inventory-II (BDI-II) and resting-state functional magnetic resonance imaging (rs-fMRI). The results showed that compared with the control group, the neglect group utilized the reappraisal strategy less frequently and displayed more depressive symptoms. The prefrontal functional connections with other brain regions in the neglect group were more robust than those in the control group using less stringent multiple correction standards. Across the two groups, the functional connection strength between the right orbitofrontal gyrus and the right middle frontal gyrus significantly negatively correlated with the ERQ reappraisal score and positively correlated with the BDI-II total score; the ERQ reappraisal score wholly mediated the relationship between the functional connection strength and the BDI-II total score. It suggests that primary CEN may closely correlate with more depressive symptoms in adulthood. Furthermore, the more robust spontaneous activity of the prefrontal lobe may also be closely associated with more depressive symptoms by utilizing a reappraisal strategy less frequently.
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Affiliation(s)
- Bin Xu
- *Correspondence: Bin Xu ✉
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Parr AC, Calabro F, Tervo-Clemmens B, Larsen B, Foran W, Luna B. Contributions of dopamine-related basal ganglia neurophysiology to the developmental effects of incentives on inhibitory control. Dev Cogn Neurosci 2022; 54:101100. [PMID: 35344773 PMCID: PMC8961188 DOI: 10.1016/j.dcn.2022.101100] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 02/23/2022] [Accepted: 03/16/2022] [Indexed: 01/19/2023] Open
Abstract
Inhibitory control can be less reliable in adolescence, however, in the presence of rewards, adolescents' performance often improves to adult levels. Dopamine is known to play a role in signaling rewards and supporting cognition, but its role in the enhancing effects of reward on adolescent cognition and inhibitory control remains unknown. Here, we assessed the contribution of basal ganglia dopamine-related neurophysiology using longitudinal MR-based assessments of tissue iron in rewarded inhibitory control, using an antisaccade task. In line with prior work, we show that neutral performance improves with age, and incentives enhance performance in adolescents to that of adults. We find that basal ganglia tissue iron is associated with individual differences in the magnitude of this reward boost, which is strongest in those with high levels of tissue iron, predominantly in adolescence. Our results provide novel evidence that basal ganglia neurophysiology supports developmental effects of rewards on cognition, which can inform neurodevelopmental models of the role of dopamine in reward processing during adolescence.
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Affiliation(s)
- Ashley C Parr
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA 14213, United States.
| | - Finnegan Calabro
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA 14213, United States; Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA 14213, United States
| | | | - Bart Larsen
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, United States
| | - Will Foran
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA 14213, United States
| | - Beatriz Luna
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA 14213, United States.
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Woody ML, Panny B, Degutis M, Griffo A, Price RB. Resting state functional connectivity subtypes predict discrete patterns of cognitive-affective functioning across levels of analysis among patients with treatment-resistant depression. Behav Res Ther 2021; 146:103960. [PMID: 34488187 PMCID: PMC8653528 DOI: 10.1016/j.brat.2021.103960] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 07/22/2021] [Accepted: 09/01/2021] [Indexed: 01/02/2023]
Abstract
Resting state functional connectivity (RSFC) in ventral affective (VAN), default mode (DMN) and cognitive control (CCN) networks may partially underlie heterogeneity in depression. The current study used data-driven parsing of RSFC to identify subgroups of patients with treatment-resistant depression (TRD; n = 70) and determine if subgroups generalized to transdiagnostic measures of cognitive-affective functioning relevant to depression (indexed across self-report, behavioral, and molecular levels of analysis). RSFC paths within key networks were characterized using Subgroup-Group Iterative Multiple Model Estimation. Three connectivity-based subgroups emerged: Subgroup A, the largest subset and containing the fewest pathways; Subgroup B, containing unique bidirectional VAN/DMN negative feedback; and Subgroup C, containing the most pathways. Compared to other subgroups, subgroup B was characterized by lower self-reported positive affect and subgroup C by higher self-reported positive affect, greater variability in induced positive affect, worse response inhibition, and reduced striatal tissue iron concentration. RSFC-based categorization revealed three TRD subtypes associated with discrete aberrations in transdiagnostic cognitive-affective functioning that were largely unified across levels of analysis and were maintained after accounting for the variability captured by a disorder-specific measure of depressive symptoms. Findings advance understanding of transdiagnostic brain-behavior heterogeneity in TRD and may inform novel treatment targets for this population.
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Affiliation(s)
- Mary L Woody
- Department of Psychiatry, University of Pittsburgh School of Medicine, USA.
| | - Benjamin Panny
- Department of Psychiatry, University of Pittsburgh School of Medicine, USA
| | - Michelle Degutis
- Heinz College of Information Systems and Public Policy, Carnegie Mellon University, USA
| | - Angela Griffo
- Department of Psychiatry, University of Pittsburgh School of Medicine, USA
| | - Rebecca B Price
- Department of Psychiatry, University of Pittsburgh School of Medicine, USA; Department of Psychology, University of Pittsburgh, USA
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