Effort-based decision making in psychopathology: A transdiagnostic multilevel meta-analysis and systematic review of behavioral patterns and mechanisms underlying amotivational psychopathology.

Abstract

Effort-based decision making (EBDM) is fundamental to motivation. This cognitive process weighs the effort required to obtain a reward against its magnitude and the probability of obtaining it. Research suggests both transdiagnostic and disorder-specific patterns and mechanisms of EBDM in individuals with schizophrenia spectrum disorders, major depressive disorder, bipolar disorder, and those at risk for these conditions. This preregistered meta-analysis (CRD42022344605) aimed to quantify EBDM across these conditions compared to healthy controls and examine mechanisms underlying altered effort allocation. PubMed, APA PsycInfo, Embase, and Web of Science databases were systematically searched for eligible studies. We synthesized 115 effect sizes from 68 studies (N = 3,697). Three-level random-effects meta-analyses revealed moderate deficits in EBDM across schizophrenia spectrum disorders (g = -0.40) and bipolar disorder (g = -0.39), a smaller impairment in major depressive disorder (g = -0.28), and no significant reductions in at-risk samples (g = -0.01). Altered effort allocation patterns were marked by reduced effort exertion across increasing reward and probability conditions, with schizophrenia spectrum disorders showing the most pronounced deficits. The most robust moderators were the number of probability conditions, ethnicity, gender, and the severity of positive and negative symptoms. A narrative synthesis of computational modeling studies indicated that maladaptive EBDM may reflect increased effort sensitivity, reduced reward sensitivity, and cognitive impairment, with variations across disorders. Whereas schizophrenia spectrum disorders are associated with unsystematic effort allocation and cognitive deficits, major depressive disorder and bipolar disorder show heightened effort sensitivity. Overall, findings point to both shared and disorder-specific mechanisms of EBDM, offering directions for targeted interventions. (PsycInfo Database Record (c) 2026 APA, all rights reserved).