Background Major depressive disorder (MDD) is a leading cause of disability worldwide, yet treatment response to antidepressants remains highly variable, with a significant proportion of patients failing to achieve remission. Resting-state functional connectivity (RSFC) studies have linked MDD to large-scale brain network dysregulation, but methodological inconsistencies and limited focus on treatment response have hindered clinical translation.

Methods In this study, we conducted a resting-state fMRI study as part of an 8-week antidepressant trial on 86 patients with MDD and 93 healthy controls (HCs). Utilizing a seed-to-voxel approach with brain regions identified in previous studies on neural networks implicated in antidepressant response, we examined RSFC patterns associated with treatment outcomes. Additionally, we explored their relationships with cognitive function and depressive severity to elucidate the neural mechanisms underlying treatment response.

Results Compared to the non-responder group, antidepressant responders exhibited significantly higher FCs between the prefrontal cortex, thalamus, amygdala, and posterior cingulate cortex (PCC). In responders, FC between the left amygdala and supramarginal gyrus, as well as the ventromedial prefrontal cortex (VMPFC) and lateral occipital cortex, was negatively correlated with cognitive scores. Conversely, in the non-responder group, FC between the left subgenual anterior cingulate cortex (sgACC) and lateral occipital cortex was negatively correlated with digit span but positively with other cognitive tasks. FCs involving the amygdala, thalamus, and VMPFC were correlated with depression scale scores.

Conclusions The present study highlights the role of intrinsic FC patterns in differentiating antidepressant responders from non-responders in MDD. Enhanced connectivity within networks related to emotion regulation, cognitive control, and attention in responders suggests neural mechanisms supporting improved emotional and cognitive flexibility.

The authors have declared no competing interest.

This study was carried out with the support of the Korea-UK (MRC) Cooperative Development Program of the National Research Foundation of Korea (NRF), funded by the Korean government (Ministry of Science and ICT) in 2023 (RS-2023-00303461).

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The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

The Institutional Review Board of Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea gave ethical approval for this work (IRB No. 2019AN0174).

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Due to privacy and ethical restrictions, the clinical and neuroimaging data supporting the findings of this study are not publicly available. However, de-identified data may be made available from the corresponding author upon reasonable request.