Acute stress reorganizes pregenual cingulate and subthalamic coupling to approach-avoidance decisions in remitted depression
Major depressive disorder (MDD) is highly recurrent, and psychosocial stress is a central precipitant of relapses. Daily choices require weighing potential rewards against costs, a process disrupted in MDD that may contribute to relapse. Here, we tested whether a psychosocial stressor affects neural and computational mechanisms underlying approach-avoidance decision making in individuals with remitted MDD (rMDD, N=50) and healthy controls (N=74), prioritizing pregenual anterior cingulate cortex (pgACC) and subthalamic nucleus (STN) due to their roles in value integration and decision caution, respectively. Participants performed a dynamic approach-avoidance conflict task with fMRI before and after psychosocial stress. Hierarchical Bayesian drift-diffusion modeling evaluated whether stress modulated computational and neural mechanisms, with trial-wise pgACC and STN activity entered as neural regressors on evidence accumulation and decision threshold, respectively. Before stress, groups did not differ in any decision parameter, but pgACC activity contributed to evidence accumulation toward avoidance in controls only. After stress, rMDD showed larger increases than controls in the impact of both reward and aversiveness on accumulation toward approach and avoidance, respectively, predominantly for net-aversive offers. Furthermore, in rMDD, stress rendered both approach and avoidance decisions more sensitive to pgACC activity, and STN activity was more strongly coupled to the decision threshold than in controls. Finally, stress-induced increases in reward sensitivity in rMDD predicted one-year course of depressive symptoms. Thus, MDD remission is not characterized by a generalized blunting of decision-making, but by a latent circuit difference that acute stress reorganizes and predicts future symptoms.