What is the recommended dosing for sertraline (Selective Serotonin Reuptake Inhibitor - SSRI) in the treatment of anxiety?

Sertraline Dosing for Anxiety

For adults with anxiety disorders (panic disorder, PTSD, social anxiety disorder), start sertraline at 25 mg once daily for one week, then increase to 50 mg once daily, with a therapeutic range of 50-200 mg/day. 1

Adult Dosing Strategy

Initial Dosing

• Start at 25 mg once daily for panic disorder, PTSD, and social anxiety disorder 1
• After one week, increase to 50 mg once daily as the initial therapeutic dose 1
• For generalized anxiety disorder, flexible dosing of 50-150 mg/day has demonstrated efficacy 2

Dose Titration

• Increase doses in 50 mg increments at intervals of no less than 1 week (due to sertraline's 24-hour elimination half-life) 1
• Maximum dose: 200 mg/day 1
• For mild to moderate anxiety, titrate at 1-2 week intervals as tolerated 3
• For severe anxiety presentations, faster up-titration may be indicated, though higher doses can increase adverse effects 3

Important Dosing Consideration

Start with a subtherapeutic "test" dose since an initial adverse effect of SSRIs can be anxiety or agitation 3

Pediatric Dosing (Ages 6-17)

For Obsessive-Compulsive Disorder

• Children (6-12 years): Start at 25 mg once daily 1
• Adolescents (13-17 years): Start at 50 mg once daily 1
• Titrate up to maximum 200 mg/day based on response 1
• Consider lower body weights when advancing doses to avoid excess dosing 1
• Dose changes should occur at intervals of no less than 1 week 1

Dosing Frequency

• At low doses of sertraline, youths may require twice-daily dosing 3
• Most patients can be maintained on once-daily dosing (morning or evening) 1

Expected Response Timeline

• Statistically significant improvement: Within 2 weeks 3
• Clinically significant improvement: By week 6 3
• Maximal improvement: By week 12 or later 3
• This logarithmic response model supports slow up-titration to avoid exceeding optimal dose 3

Critical Safety Monitoring

Black Box Warning

• All SSRIs carry a boxed warning for suicidal thinking and behavior through age 24 3
• Close monitoring is essential, especially in the first months of treatment and following dosage adjustments 3
• Number needed to harm: 143 (versus number needed to treat: 3) 3

Common Adverse Effects

• Nausea, diarrhea, headache, insomnia, dizziness, dry mouth, somnolence 3
• Most adverse effects emerge within the first few weeks of treatment 3

Discontinuation Syndrome

• Sertraline is associated with discontinuation syndrome (though less than paroxetine) 3
• Symptoms include dizziness, fatigue, nausea, sensory disturbances, anxiety, irritability 3
• Taper gradually when discontinuing 3

Drug Interactions

• Contraindicated with MAOIs due to serotonin syndrome risk 3
• May interact with drugs metabolized by CYP2D6 3
• Exercise caution when combining with other serotonergic drugs 3
• Monitor for serotonin syndrome symptoms within 24-48 hours after combining medications 3

Combination Therapy Consideration

For children and adolescents (6-18 years) with social anxiety, generalized anxiety, separation anxiety, or panic disorder, combination treatment (CBT + sertraline) is superior to monotherapy 3

Maintenance Treatment

• Anxiety disorders typically require continuing therapy 3
• In panic disorder, sertraline (50-175 mg/day) provides protection from relapse for up to 36 weeks following withdrawal 4
• Most patients experience return of symptoms upon discontinuation 3