A systematic review of neuroimaging studies of clozapine-resistant schizophrenia

Tiffanie Sze Wing PANG, Johnny Siu Wah CHUN, Ting Yat WONG, Sin Ting CHU, Chak Fai MA, William G. HONER, Sherry Kit Wa CHAN

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2 Citations (Scopus)


This systematic review aimed to review neuroimaging studies comparing clozapine-resistant schizophrenia patients with clozapine-responding patients, and with first-line antipsychotic responding (FLR) patients. A total of 19 studies including 6 longitudinal studies were identified. Imaging techniques comprised computerized tomography (CT, n = 3), structural magnetic resonance imaging (MRI, n = 7), magnetic resonance spectroscopy (MRS, n = 5), functional MRI (n = 1), single-photon emission computerized tomography (SPECT, n = 3) and diffusion tensor imaging (DTI, n = 1). The most consistent finding was hypo-frontality in the clozapine-resistant group compared with the clozapine-responding group with possible differences in frontal-striatal-basal ganglia circuitry as well as the GABA level between the two treatment-resistant groups. Additional statistically significant findings were reported when comparing clozapine-resistant patients with the FLR group, including lower cortical thickness and brain volume of multiple brain regions as well as lower Glx/Cr level in the dorsolateral prefrontal cortex. Both treatment-resistant groups were found to have extensive differences in neurobiological features in comparison with the FLR group. Overall results suggested treatment-resistant schizophrenia is likely to be a neurobiological distinct type of the illness. Clozapine-resistant and clozapine-responding schizophrenia are likely to have both shared and distinct neurobiological features. However, conclusions from existing studies are limited, and future multi-center collaborative studies are required with a consensus clinical definition of patient samples, multimodal imaging tools, and longitudinal study designs. Copyright © 2023 The Author(s).

Original languageEnglish
Article number65
Early online dateSept 2023
Publication statusPublished - 2023


Pang, T. S. W., Chun, J. S. W., Wong, T. Y., Chu, S. T., Ma, C. F., Honer, W. G. & Chan, S. K. W. (2023). A systematic review of neuroimaging studies of clozapine-resistant schizophrenia. Schizophrenia, 9, Article 65. https://doi.org/10.1038/s41537-023-00392-7


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