Phenelzine, sold under the brand name Nardil among others, is a non-selective and irreversible monoamine oxidase inhibitor (MAOI) of the hydrazine family which is primarily used as an antidepressant and anxiolytic to treat depression and anxiety. Along with tranylcypromine and isocarboxazid, phenelzine is one of the few non-selective and irreversible MAOIs still in widespread clinical use.

Phenelzine is primarily used in the treatment of major depressive disorder, including treatment-resistant depression. Modern guidance on classic MAOIs recommends considering phenelzine, tranylcypromine, or isocarboxazid after insufficient response to other antidepressant treatments and before electroconvulsive therapy when a rapid treatment response is not required.

Patients with atypical depression may respond particularly well to phenelzine, but evidence also supports the use of classic MAOIs in melancholic depression. Phenelzine may be especially useful when depression is accompanied by premorbid anxiety, comorbid panic disorder, or other treatment-resistant anxiety symptoms, reflecting its additional effects on GABA metabolism.

Phenelzine has also been studied or used in anxiety-related and other psychiatric conditions including panic disorder, social anxiety disorder, post-traumatic stress disorder (PTSD), obsessive–compulsive disorder (OCD), dysthymia, bipolar depression, and bulimia nervosa.

Common or clinically important adverse effects of phenelzine include orthostatic hypotension, dizziness, dry mouth, constipation, urinary retention, sedation or somnolence, insomnia, weight gain, edema, sweating, sexual dysfunction, and reduced vitamin B₆ levels or pyridoxine deficiency. Hypoglycemia and clinically relevant cytochrome P450 interactions may also occur, particularly with hydrazine MAOIs such as phenelzine.

Rare adverse effects reported with phenelzine include hypomania or mania, psychosis, hepatotoxicity, and acute liver failure, the last of which has been reported mainly in susceptible individuals, including people with pre-existing liver damage, old age, long-term effects of alcohol consumption, or viral infection.

Phenelzine is contraindicated in patients who are unable or unwilling to follow the required dietary tyramine restrictions and medication precautions, and in patients with pheochromocytoma because of the risk of hypertensive emergency. This contraindication reflects a preventable risk: tyramine-related hypertensive emergencies are uncommon when dietary and medication precautions are followed, and modern food standards have substantially reduced excessive tyramine exposure compared with the period when MAOIs were first introduced. It is also contraindicated with drugs, supplements, or recreational drugs that have significant serotonin reuptake inhibition or significant serotonin-releasing activity, because of the risk of serotonin toxicity. Examples include selective serotonin reuptake inhibitors (SSRIs), serotonin–norepinephrine reuptake inhibitors (SNRIs), clomipramine, imipramine, MDMA, and certain analgesics such as meperidine, tramadol, methadone, tapentadol, dextromethorphan, dextropropoxyphene, pentazocine, and levorphanol.

Concomitant use of multiple MAO-inhibiting agents is generally listed as contraindicated or avoided in prescribing guidance. For combinations of classic MAOIs with one another, the caution is based mainly on limited safety data and the fact that routine long-term coadministration usually has little therapeutic rationale, since classic MAOIs already inhibit both MAO-A and MAO-B irreversibly. This concern is not the same as the serotonin-toxicity risk seen when MAOIs are combined with drugs that significantly inhibit serotonin reuptake or release serotonin. A classic MAOI-to-classic MAOI overlap is not expected to cause serotonin toxicity unless another serotonergic drug with clinically significant serotonin reuptake inhibition or serotonin-releasing activity is also involved.