Can sertraline (selective serotonin reuptake inhibitor) be used for the treatment of anxiety?

Sertraline for Treatment of Anxiety

Sertraline is strongly recommended for the treatment of anxiety disorders, including social anxiety disorder, generalized anxiety disorder, separation anxiety, and panic disorder, based on substantial empirical evidence supporting its effectiveness and safety. 1

Efficacy of Sertraline for Anxiety Disorders

• Sertraline belongs to the selective serotonin reuptake inhibitor (SSRI) class, which has been shown to improve primary anxiety symptoms (based on parent and clinician reports), response to treatment, remission rates, and global functioning compared to placebo 1

• Sertraline has demonstrated efficacy in treating multiple anxiety disorders including:

  • Social anxiety disorder 2
  • Generalized anxiety disorder 3
  • Panic disorder 4
  • Post-traumatic stress disorder 5

• In severe generalized social anxiety disorder, sertraline produced significantly greater reduction in anxiety symptoms compared to placebo (55.6% vs. 29% response rate among completers) 2

Mechanism of Action

• Sertraline inhibits the presynaptic reuptake of serotonin in the brain, increasing serotonin availability at the synaptic cleft 1
• This mechanism is believed to play a key role in modulating fear, worry, and stress responses, as well as facilitating cognitive processing of emotions 1
• The therapeutic effect typically follows a logarithmic model with:
  • Statistically significant improvement within 2 weeks
  • Clinically significant improvement by week 6
  • Maximal improvement by week 12 or later 1

Dosing Considerations

• For anxiety disorders, sertraline is typically used in flexible doses ranging from 50-200 mg/day 2
• At low doses, sertraline may require twice-daily dosing due to its shorter half-life compared to some other SSRIs 1
• A conservative approach for mild to moderate anxiety includes:
  • Starting with a subtherapeutic "test" dose to minimize initial anxiety/agitation
  • Increasing the dose at 1-2 week intervals in small increments
  • Titrating until optimal benefit-to-harm ratio is achieved 1

Side Effects and Safety

• Sertraline is generally well-tolerated with a favorable side effect profile compared to older antidepressants 6
• Common side effects may include:
  • Gastrointestinal symptoms (nausea, diarrhea, heartburn)
  • Headache, somnolence, insomnia, dizziness
  • Changes in appetite or weight 1
• More serious but less common adverse effects include:
  • Suicidal thinking and behavior (particularly in young adults under 24)
  • Serotonin syndrome (when combined with other serotonergic medications)
  • Sexual dysfunction 1, 5
• Sertraline has a boxed warning for increased risk of suicidal thinking and behavior in children, adolescents, and young adults up to age 24 5

Special Considerations

• Sertraline should not be used concurrently with:
  • MAO inhibitors (including linezolid)
  • Pimozide
  • Disulfiram (if using liquid sertraline) 5
• Caution is advised when combining sertraline with:
  • Blood thinners (increased bleeding risk)
  • Other serotonergic medications (risk of serotonin syndrome)
  • QT-prolonging medications 1, 5
• Discontinuation should be gradual to avoid withdrawal symptoms, which can include dizziness, sensory disturbances, anxiety, and irritability 1

Combination Treatment

• For children and adolescents with anxiety disorders, combining sertraline with cognitive behavioral therapy (CBT) has shown superior outcomes compared to either treatment alone 1
• In adults with social anxiety disorder, both SSRIs and CBT are recommended treatment options, though there is insufficient evidence to make a definitive recommendation regarding combination therapy 1

Treatment Duration

• For anxiety disorders, sertraline has demonstrated efficacy in both acute treatment and relapse prevention 4, 7
• Long-term use should be periodically reevaluated to assess continued benefit 5

Conclusion

Sertraline represents an effective first-line pharmacological treatment for various anxiety disorders with a favorable tolerability profile and low potential for pharmacokinetic drug interactions 6, 7. While no specific SSRIs have FDA approval specifically for anxiety disorders in children and adolescents, substantial empirical evidence supports their use, with sertraline being one of the most well-studied options 1.