Augmentation of paroxetine with clocapramine in panic disorder


Masanori Saito, md, phd, Department of Psychiatry, Kitasato University School of Medicine, 2-1-1 Asamizodai, Sagamihara, Kanagagawa 228-8520, Japan. Email:

Clocapramine (CCP) is an iminodibenzyl antipsychotic drug with psychomotor stimulant activity.1 To the authors' knowledge there are few papers concerning the use of CCP for disorders other than schizophrenia. Reported herein is a case of panic disorder successfully treated by the addition of CCP to paroxetine.

The patient, 35 years old at the time of writing, presented with a history of panic disorder since the birth of her first child at the age of 16 years. From the age of 20 years the patient had been on regular treatment with alprazolam (0.8 mg daily); nonetheless, she suffered from panic attacks almost every week.

The patient consulted Kitasato University East hospital when she was 26 years old. The results of routine tests were all normal. The treatment with alprazolam was combined with psychotherapy but the attacks persisted, although they occurred only once every several weeks. The patient had had to be taken to emergency services for severe attacks approximately twice a year.

When the patient was 27 years old, add-on therapy with imipramine (max. 30 mg daily) was started but this proved to have no effect. Later, amoxapine (max. 105 mg daily), instead of imipramine, also proved to be ineffective.

When amoxapine was switched to paroxetine (20 mg daily) at the age of 30 years, a general decrease in the severity of the attacks was noted, and since then she has never had to call for ambulance services. Nonetheless, the attacks still continued to occur once every several weeks.

After the patient delivered her second child when she was 32 years old, the panic attacks began to occur almost every week. Paroxetine (40 mg daily) had only been partially effective.

Chlorpromazine (25 mg daily) was added to paroxetine when the patient was 33 years old, which resulted in a reduction in the frequency of the attacks to approximately once a month.

When the patient was 34 years old, chlorpromazine was switched to clocapramine (CCP) at a daily dose of 30 mg. Since then she has not suffered from any panic attacks. Three months after it was started, CCP was reduced to 20 mg daily because of the development of slight akathisia.

At present the patient has not experienced any panic attacks for more than 14 months, although she has suffered from occasional palpitations and a persistent fear of recurrence of the attacks.

Although we sometimes encounter patients with panic disorder who respond to the combination of an antidepressant and chlorpromazine, we chose CCP for the present patient because she complained of loss of volition after being started on chlorpromazine. It is of special interest whether carpipramine, the first iminodibenzyl antipsychotic drug,2 is also effective for panic disorder.