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Magnetic resonance imaging (MRI) is a technique used to in radiology to form an image of the physiological processes of the body and anatomy of the body. It is an non-invasive method with no damage to the body. This paper will discuss the use of MRI in the diagnosis of depression, which in turn will provide a valuable diagnosis method.

Structural brain changes associated with depression:
Changes in the anatomy of the brain are generally denoted as differences in volume and are assessed by structural MRI. Other types of psychiatric disorders are also associated with numerous structural alterations that occur in people with MDD. Compared to the control, studies reported the insignificance of the alterations in the total volume of gray matter and whole-brain volume. Ventricular changes are also commonly described in MDD patients which are also consistent with other psychiatric disorders. In 1983, a study conducted by the Medical Centre of the University of Nebraska became the first to report a lateral ventricular enlargement in MDD patients. Nevertheless, since at that time (e.g., in 1983), MRI was not accessible due to its being a relatively novel approach, the earlier studies used computed tomography (CT) to detect ventricular alterations associated with MDD. Kempton and colleagues conducted a recent meta-analysis in which they assessed ventricular enlargement. Compared to healthy individuals by MRI, patients with MDD exhibited an increase in the volume of cerebrospinal fluid (CSF) and enlargement of the lateral ventricle. Despite being commonly associated with MDD patients, ventricular enlargement also occurs naturally as people get older.

= Consistency in the structural brain changes in individuals with depression: =

A recent study investigated the presence of an association between particular structural changes in the brain and the lifetime episodes of MDD in 610 MDD patients and compared them with healthy individuals and determined whether the structural alterations were affected by the genotype, age, or gender. The study found that there is a higher likelihood of decreased volumes of the nucleus accumbens, pallidum, thalamus, and insula in individuals with lifetime MDD, additionally, these decreases were not affected by gender. Nevertheless, gender affected specific brain alterations as female MDD patients were more likely to show increased volumes of rostral anterior cingulate cortex as well as lower incidence of reduced caudate nucleus volumes as opposed to male MDD patients. Smaller nuclear accumbens and ventral diencephalon volumes were detected in patients with early-onset first-episode MDD, while increased pericalcarine regions and rostral anterior cingulate cortexes were associated with patients who had their first depressive episode when they were above the age of 50 years (i.e. late-onset first episode MDD). Moreover, the study also reported a positive association between 5-HTTLPR (serotonin transport polymorphism) genotype and specific structural alterations.

= Changes in the structure of the brain associated with antidepressants in depression =

The structure of the brain can be affected by strict adherence to antidepressants. Although half of the patients with first-onset MDD effectively responded to antidepressants, it took up to 240 days for the recurrence patient's response to the antidepressants. Patients whose response to common antidepressants is potentially very low or not present at all can be diagnosed with the use of MRI before initiating treatment, this, in turn, will be helpful while setting the treatment plan. It was found that there was a positive association between the therapeutic response level and the volumes of the right and left angular gyri.

= Functional MRI for assessing depression: = The activation of specific areas of the brain can be visualized by using a combination of anatomical imaging techniques such as CT or MRI along with functional brain imagining (fMRI) which measures metabolism and blood flow. The functional brain activity was assessed using fMRI that depends on the blood oxygenation level (BOLD) in the majority of fMRI research. The BOLD is based on the fact that when specific brain regions are activated, oxygen use increases which results in an elevation of the oxygenated blood inflow leading to higher signal on BOLD. In return, BOLD allows for global and regional mapping of brain areas activated during task-related activities and non-task (i.e., rest) activities. As patients with depression produce proto-typical activation patterns, different patterns were reported in patients performing task-related activities and at rest.

= Functional brain changes associated with depression: =

Specific brain regions activation can be used to detect functional brain alterations. Healthy individuals have different functional brain alterations than those of MDD patients. During passive rest of the brain, the default mode network (DMN) (i.e. precuneus, posterior cingulate cortex, and ventromedial prefrontal cortex) is primarily active. The DMN undergoes attenuation during tasks that require cognitive awareness and attention. For MDD patients, those who are treatment-resistant and those who are treatment-sensitive can be differentiated through the use of the hypoconnectivity of the cognitive control network and the hyperconnectivity of the DMN. Moreover, different vital regions of the DMN in MDD patients showed instability.

There is a heated debate concerning the frontal lobe alterations in patients with MDD. Grimm et al. conducted a recent study in which they reported that during self-referential processing of positive stimuli, decreased activity was detected in the precuneus, Supragenual anterior cingulate cortex, dorsomedial thalamus, and dorsomedial PFC in MDD patients. Nevertheless, the previous study may have had some unintended bias as the patients included in the study had acute MDD. A different study reported that during self-referential processing of positive stimuli, the anterior cingulate cortex and the medial PFC of MDD patients showed elevated activity.

Functional alterations occurring in the temporal lobe were not sufficiently investigated. One study reported that during loss events, there was an increase in the hippocampal activation levels of MDD patients who showed no response to treatment. Some scientists argue that MDD assessment requires stationary and linearity signals that are lacking in the resting-state fMRI commonly used in most studies. Yu and colleagues cleared this issue by utilizing the Hilbert-Huang transformation. The pathophysiology of MDD may be affected by the temporal lobe as there is an association between functional changes in the activity of the whole caudate nucleus, left amygdala, right parahippocampal gyrus, and right hippocampus of the MDD patients as opposed to healthy individuals.

There is a potential correlation between treatment response and elevated activity of the thalamus shown in MDD individuals. The states of wakefulness and sleep of MDD patients are often affected and the role of the thalamus is to regulate such activities. One study reported a direct association between MDD female patients and the decrease in the hippocampal volume. Furthermore, MDD patients showed a decrease in regional homogeneity (RoHo) in their left cerebellum and right insula, however, the significance of these findings should undergo further investigation.

Using imaging studies to differentiate mental disorders is hindered by the similarity of the functional brain alterations in some psychiatric disorders. Nevertheless, scientists have been trying to identify those differences that may provide accuracy in the differentiation of mental disorders. For instance, MDD patients were assessed by Yang et al. using resting-state fMRI with the RoHo method. There was a significant difference in the RoHo values between the partial and frontal cortexes of healthy individuals and MDD patients. Furthermore, it was later supported that bipolar disorder and MDD could be differentiated by the difference in the RoHo. Insight into novel technologies and strategies were provided by the studies as the medical imaging use in psychiatry was limited by the effective differentiation of mental disorders.

= Consistency of functional brain changes associated with depression: =

There is a lack of consistency among patients which may lead to difficulty in assessing functional imaging. For instance, functional brain changes associated with MDD are age-dependent, as the activity patterns of MDD adult patients are different from those of young and adolescent MDD patients. Furthermore, functional patterns are different in chronic MDD patients compared to first-episode MDD individuals.

MDD patients who do not receive medication have their PFC, particularly the right prefrontal regions, activated by the working memory. Yuksel et al. conducted a recent study in which they compared the activation patterns between MDD patients with a recurrent depressive episode and those with first-episode MDD. Various frontoparietal brain regions e.g. (the superior frontal gyrus, angular gyrus, and thalamus) showed significant differences in the BOLD signals. Furthermore, compared to control, MDD patients with recurrent depressive episodes had significant impairment of their working memory. There is a strong consistency in the functional and structural alterations of the parietal lobe which may require additional research to determine the possible role of the parietal lobe concerning MDD pathophysiology.

= Functional network changes associated with depression: =

Functional imaging helps compare the activity maps of the brain between individuals with mental disorders and the general healthy population as well as facilitating the investigation of the brain activity. Moreover, knowledge of the aetiology and pathology of the disease can be provided by functional imaging. Nevertheless, the clinical use of functional imaging is limited as the functional brain networks are inherently complex. Functional networks are crucial in life. For instance, when individuals are resting or daydreaming, activity occurs in their DMN. The interaction and connection of specific brain regions are facilitated through the complex interconnections. Although everyday life requires functional network connectivity, various mental disorders (e.g. bipolar disorder, schizophrenia, MDD, etc.) showed changes in functional brain connectivity.

= Conclusion: =

fMRI use in the diagnosis of depression is promising. It will unveil the aetiology of depression and the effect of depression on brain areas, which in turn will give a better understanding of how depression affects the human brain.