This article provides a comprehensive examination of test-retest reliability in functional magnetic resonance imaging (fMRI) for researchers and drug development professionals. Converging evidence indicates poor to moderate reliability for common fMRI measures, with meta-analyses reporting mean intraclass correlation coefficients (ICCs) of 0.397 for task-based activation and 0.29 for edge-level functional connectivity. We explore foundational concepts of reliability measurement, methodological factors influencing consistency, optimization strategies for improving reliability, and validation approaches across different contexts. The content synthesizes recent evidence on how analytical decisions, acquisition parameters, and processing pipelines impact reliability, providing practical guidance for enhancing fMRI's utility in clinical trials and biomarker development.
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