Dissociation of Cognitive Effort–Based Decision Making and Its Associations With Symptoms, Cognition, and Everyday Life Function Across Schizophrenia, Bipolar Disorder, and Depression

Background: Anhedonia and amotivation are symptoms of many different mental health disorders that are frequently associated with functional disability, but it is not clear whether the same processes contribute to motivational impairments across disorders. This study focused on one possible factor, the willingness to exert cognitive effort, referred to as cognitive effort–cost decision making. Methods: We examined performance on the deck choice task as a measure of cognitive effort–cost decision making, in which people choose to complete an easy task for a small monetary reward or a harder task for larger rewards, in 5 groups: healthy control (n = 80), schizophrenia/schizoaffective disorder (n = 50), bipolar disorder with psychosis (n = 58), current major depression (n = 60), and past major depression (n = 51). We examined cognitive effort–cost decision making in relation to clinician and self-reported motivation symptoms, working memory and cognitive control performance, and life function measured by ecological momentary assessment and passive sensing. Results: We found a significant diagnostic group × reward interaction (F_8,588 = 4.37, p < .001, η_p ² = 0.056). Compared with the healthy control group, the schizophrenia/schizoaffective and bipolar disorder groups, but not the current or past major depressive disorder groups, showed a reduced willingness to exert effort at the higher reward values. In the schizophrenia/schizoaffective and bipolar disorder groups, but not the major depressive disorder groups, reduced willingness to exert cognitive effort for higher rewards was associated with greater clinician-rated motivation impairments, worse working memory and cognitive control performance, and less engagement in goal-directed activities measured by ecological momentary assessment. Conclusions: These findings suggest that the mechanisms contributing to motivational impairments differ among individuals with psychosis spectrum disorders versus depression.