, Volume 14, Issue 3, pp 750–761 | Cite as

Clozapine as a Model for Antipsychotic Development

  • Frederick C. NuciforaJr
  • Marina Mihaljevic
  • Brian J. Lee
  • Akira Sawa


Schizophrenia is a devastating illness that affects up to 1% of the population; it is characterized by a combination of positive symptoms, negative symptoms, and cognitive impairment. Currently, treatment consists of one class of medications known as antipsychotics, which include typical (first-generation) and atypical (second-generation) agents. Unfortunately, antipsychotic medications have limited efficacy, with up to a third of patients lacking a full response. Clozapine, the first atypical antipsychotic developed, is the only medication shown to be superior to all other antipsychotics. However, owing to several life-threatening side effects and required enrollment in a registry with routine blood monitoring, clozapine is greatly underutilized in the US. Developing a medication as efficacious as clozapine with limited side effects would likely become the first-line therapy for schizophrenia and related disorders. In this review, we discuss the history of clozapine, landmark studies, and its clinical advantages and disadvantages. We further discuss the hypotheses for clozapine’s superior efficacy based on neuroreceptor binding, and the limitations of a receptor-based approach to antipsychotic development. We highlight some of the advances from pharmacogenetic studies on clozapine and then focus on studies of clozapine using unbiased approaches such as pharmacogenomics and gene expression profiling. Finally, we examine how these approaches could provide insights into clozapine’s mechanism of action and side-effect profile, and lead to novel and improved therapeutics.

Key Words

Clozapine Schizophrenia Antipsychotic Treatment refractory Pharmacogenomics Gene expression profiling 



This work was supported by the National Institute of Mental Health MH-094268 Silvio O. Conte center, MH-092443, MH-105660 (AS); National Institute on Drug Abuse DA-040127 (AS); foundation grants from Stanley, S-R, RUSK, NARSAD, Maryland Stem Cell Research Fund (AS). We would also like to thank Yukiko Lema for help with this manuscript.

Required Author Forms Disclosure forms provided by the authors are available with the online version of this article.

Supplementary material

13311_2017_552_MOESM1_ESM.docx (12 kb)
ESM 1 (DOCX 11 kb)


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Copyright information

© The American Society for Experimental NeuroTherapeutics, Inc. 2017

Authors and Affiliations

  • Frederick C. NuciforaJr
    • 1
  • Marina Mihaljevic
    • 2
  • Brian J. Lee
    • 1
  • Akira Sawa
    • 1
  1. 1.Department of Psychiatry and Behavioral SciencesJohns Hopkins University School of MedicineBaltimoreUSA
  2. 2.Clinic for PsychiatryClinical Center of SerbiaBelgradeSerbia

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