Effort-Cost Decision-making Among Individuals With Schizophrenia

Abstract

ImportanceMotivational impairments in schizophrenia are by definition associated with poor outcome. It is postulated that the reduction of goal-directed behavior arises from abnormal trade-offs between rewards and efforts.ObjectiveTo examine whether schizophrenia is associated with impairments in effort-cost decision-making.Data SourcesFor this systematic review and meta-analysis, the PubMed, ScienceDirect, PsycINFO, Embase, and ClinicalTrials.gov databases were searched from inception to July 2022 for studies that investigated effort-cost decision-making in schizophrenia. Search terms included effort, cost, and schizophrenia.Study SelectionConsensual criteria for inclusion were peer-reviewed studies published in English that used a computerized effort-cost decision-making behavioral paradigm and compared individuals with schizophrenia with control individuals.Data Extraction and SynthesisThe Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline was used for abstracting data. Data were extracted independently by 2 authors and then pooled using random-effects sizes and bayesian approaches.Main Outcomes and MeasuresThe main outcomes were performance on effort-cost decision-making tasks requiring an effort-reward trade-off, measured by Hedges g effect size. Effects of moderators were tested with meta-regressions and subgroup analyses.ResultsTwenty studies involving 1503 participants were included: 837 individuals with schizophrenia (541 [64.6%] male; mean [SD] age, 35.89 [6.70] years) and 666 control individuals without schizophrenia (360 [54.1%] male; mean [SD] age, 34.16 [5.92] years). Participants with schizophrenia had significantly reduced willingness to expend effort for rewards compared with controls (k = 20; effect size, 0.43; 95% CI, 0.30-0.56; P < .001; I2 = 33.1%; Q test P = .08). The magnitude of the deficit was significantly greater for high-reward trials. The severity of negative symptoms was negatively associated with effort-cost decision-making (k = 8; effect size, −0.33; 95% CI, −0.50 to −0.15; P < .001), while participants with a high number of negative symptoms had a significantly larger impairment in effort-cost decision-making (k = 5; effect size, 0.47; 95% CI, 0.10-0.84; P = .01).Conclusions and RelevanceIn this systematic review and meta-analysis, schizophrenia was associated with deficits in effort allocation as indexed by effort-cost decision-making tasks. Understanding the cognitive and neurobiological mechanisms driving effort allocation impairments may assist in developing novel interventions.

Effort-Based Decision-Making in Psychopathology: A transdiagnostic multilevel meta-analysis

“…Compared to healthy controls, the overall deficit in EBDM in SSD was significant with a moderate effect size (g = -.37). This is consistent with a previous meta-analysis and substantiates the available evidence by including a considerably higher number of study-level effect sizes (k = 48 vs. k = 20; Blouzard et al, 2023). Moreover, this meta-analysis is the first to complement previous systematic reviews on EBDM deficits in MDD by a meta-analytic aggregation of the available data (e.g., Horne et al, 2021).…”

“…It is worth noting that the differences between both groups and controls was nonsignificant in trials with low reward/probability and that the largest difference between clinical groups and controls was evident in high reward/probability trials. This resembles the observation of the previous meta-analysis of EBDM in SSD (Blouzard et al, 2023) and illuminates similar, yet less pronounced, patterns of maladaptive effort allocation in MDD. Consequently, EBDM deficits are best characterized as a transdiagnostic pattern of maladaptive allocation of effort to increasing reward and probability rather than as a generalized lack of motivation, which would be also reflected by reduced effort in low reward/probability trials.…”

“…Given that EBDM tasks have been developed and promoted as 'objective measures of motivational negative symptoms' (Green et al, 2015;Hartmann-Riemer et al, 2018), it is surprising that the effects between clinical groups and controls were not moderated by clinician-rated negative symptoms, neither in the current nor in the previous meta-analysis (Blouzard et al, 2023). This suggests that EBDM does not capture the same aspects of amotivational psychopathology as clinician-rated negative symptom scales.…”

“…An important recent meta-analysis including 20 studies compared performance on these tasks between people with SSD and healthy controls (HC). Overall, participants with SSD exerted significantly less effort than controls with a medium effect size (Blouzard et al, 2023). Based on subgroup analyses (k = 9), differences between SSD participants and controls in trials with low-reward magnitude and probability were not significant, but there were significant and large group differences in trials with high-reward magnitude and probability.…”

Cognitive subgroups and the relationships with symptoms, psychosocial functioning and quality of life in first-episode non-affective psychosis: a cluster-analysis approach

“…Alternatively, diminished motivation (or termed amotivation), a core subdomain of negative symptoms, was found to adversely influence cognitive performance in schizophrenia patients ( 57 ). Accumulating evidence demonstrated that schizophrenia patients exhibited effort-based decision-making impairment, with reduced willingness to expend effort for reward being associated with more severe amotivation ( 58 ). Our recent report further indicated significant association between decreased “cognitive” effort expenditure and higher levels of amotivation in FEP patients ( 59 ).…”