Tricyclic Antidepressant (TCA) — OCD Specialist Pregnancy: Not recommended during pregnancy and in women of childbearing potential not using contraception. First-trimester data do not suggest increased overall congenital anomalies but risk of cardiac (septal) defects was increased; neonates exposed up to delivery have developed withdrawal-type symptoms.

Clomipramine

Brand names: Anafranil

Clomipramine is a tricyclic antidepressant used for depression, obsessive-compulsive disorder and phobic and panic disorders.

Auto-extracted from the source labelling — not yet independently clinician-verified. These values were distilled from the UK SPC (or the US label where noted) but have not had a clinician sign-off. Confirm against the current SmPC before prescribing.

Adult dose

Dose: 10 mg/day initially, increasing gradually to 30-150 mg/day

Route: oral

Frequency: in divided doses throughout the day or as a single dose at bedtime

Max: 250 mg per day (severe cases)

Depression: 10 mg/day initially, increasing gradually to 30-150 mg/day if required; many patients adequately maintained on 30-50 mg/day; in severe cases up to a maximum of 250 mg/day; once distinct improvement occurs, maintenance about 50-100 mg/day. Obsessional/phobic states: build up to 100-150 mg daily over ~2 weeks starting at 25 mg daily. Adjunctive treatment of cataplexy with narcolepsy: 10-75 mg daily (start 10 mg, max 75 mg/day). Elderly: initial dose 10 mg/day, increased cautiously to 30-75 mg daily reached after about 10 days. Before initiating, treat hypokalaemia. Avoid abrupt discontinuation - taper gradually. Give with caution in renal or hepatic impairment. Paediatric population: not recommended (must not be used for depression, phobias or cataplexy of narcolepsy in under-18s).

Dose adjustments

Renal

Should be given with caution in patients with renal impairment.

Dose auto-extracted from UK Summary of Product Characteristics (SPC) via the eMC; US FDA prescribing information (openFDA / DailyMed) — cross-check; US labelling may differ from UK — not yet clinician-verified. Always confirm against the product SmPC and your local formulary before prescribing.

Contraindications

Hypersensitivity to clomipramine/excipients or cross-sensitivity to dibenzazepine-group tricyclic antidepressants
Recent myocardial infarction, any degree of heart block or other cardiac arrhythmias
Severe liver disease
Concurrent monoamine oxidase inhibitors, or within 3 weeks of starting/stopping MAOI therapy
Concomitant selective reversible MAO-A inhibitors such as moclobemide
Narrow-angle glaucoma
Retention of urine
Mania

Side effects

Dry mouth, constipation, nausea
Increased appetite
Dizziness, tremor, headache, myoclonus, somnolence
Restlessness
Accommodation disorder / blurred vision, hyperhidrosis

Interactions

MAO inhibitors - contraindicated (risk of serotonin syndrome / hypertensive reactions)
Other serotonergic agents and QT-prolonging drugs - caution; risk of serotonergic toxicity / QTc prolongation
Anticholinergic or sympathomimetic drugs - close supervision and careful dose adjustment
Hepatic enzyme inhibitors (e.g. cimetidine, fluoxetine), haloperidol, methylphenidate - increased clomipramine plasma levels
Hepatic enzyme inducers (e.g. barbiturates, phenytoin) - decreased clomipramine plasma levels
Guanethidine, clonidine or similar agents - clomipramine may block their pharmacologic effects

Clinical monograph

How it works

It inhibits the reuptake of serotonin and noradrenaline, with additional antimuscarinic, antihistaminic and alpha-adrenergic blocking actions.

Prescribing in practice

It is dangerous in overdose, causing cardiac arrhythmias, seizures and coma, so caution is needed in patients at risk of suicide and in cardiac disease.
Antimuscarinic effects, postural hypotension and lowering of the seizure threshold are common.
Avoid combination with monoamine oxidase inhibitors and other serotonergic drugs because of the risk of serotonin syndrome.

Monitoring

Monitor mood, suicidality, cardiac status where relevant and antimuscarinic and cardiovascular side effects.

Counselling the patient

Improvement may take several weeks; keep taking it as prescribed.
Report palpitations, fainting, confusion or worsening mood urgently.
Do not stop suddenly, as withdrawal symptoms can occur.

Evidence & guidelines

Clomipramine has established efficacy in obsessive-compulsive disorder and depression supported by randomised controlled trials.

Reference: NICE CG31 (OCD); Drug verified in RxNorm (NLM); confirm dosing against the manufacturer SPC (eMC). Verify against your local formulary and current prescribing references before prescribing. The structured dose values shown have been reviewed by a clinician. Monograph status: clinician-reviewed (2026-07-04).

Curated clinical cross-links plus same-class fallbacks.

Calculators

Pathways