What is the recommended starting dose of sertraline (selective serotonin reuptake inhibitor)?

Starting Dose of Sertraline

The recommended starting dose of sertraline is 50 mg once daily for adults with major depressive disorder and obsessive-compulsive disorder, while panic disorder, PTSD, and social anxiety disorder should begin at 25 mg once daily for one week before increasing to 50 mg once daily. 1

Adult Dosing by Indication

Major Depressive Disorder and OCD

• Start with 50 mg once daily as both the initial and typically effective therapeutic dose 1
• This 50 mg starting dose represents the optimal balance of efficacy and tolerability for most patients 2
• May be administered at any time of day (morning or evening) 1

Panic Disorder, PTSD, and Social Anxiety Disorder

• Begin at 25 mg once daily for the first week 1
• Increase to 50 mg once daily after one week 1
• This lower initial dose helps minimize early side effects in these anxiety-related conditions

Premenstrual Dysphoric Disorder

• Start with 50 mg daily, either throughout the menstrual cycle or limited to the luteal phase 1
• Dose increases can be made in 50 mg increments up to 150 mg/day (continuous dosing) or 100 mg/day (luteal phase dosing) 1

Pediatric Dosing (Ages 6-17)

Children (6-12 years)

• Start with 25 mg once daily for OCD 3, 1
• Lower body weight necessitates this reduced starting dose to avoid excess dosing 1

Adolescents (13-17 years)

• Start with 50 mg once daily for OCD 3, 1
• Pharmacokinetic studies demonstrate that weight-normalized parameters are similar between children and adolescents 4

Dose Titration Principles

• Wait at least one week between dose adjustments due to sertraline's 24-hour elimination half-life 1
• Patients not responding to initial 50 mg dose may benefit from increases up to maximum 200 mg/day 3, 1
• Increase in 50 mg increments for adults 1
• For pediatric patients, titration up to 200 mg/day is possible, but body weight should guide dosing decisions 1

Special Populations

Elderly Patients

• No dose adjustment needed based on age alone 1, 5, 6
• Start with standard adult dose of 50 mg daily 5, 6
• Sertraline has favorable tolerability in elderly patients compared to tricyclic antidepressants, lacking significant anticholinergic effects 5, 6
• Low potential for drug interactions makes it particularly suitable for elderly patients on multiple medications 5, 6

Off-Label Use for Premature Ejaculation

• Daily dosing: 50-200 mg is effective for delaying ejaculation 7
• On-demand dosing 3-6 hours before intercourse is less effective than daily treatment 7
• Paroxetine shows stronger ejaculation delay than sertraline in this indication 7

Critical Safety Considerations

Monitoring Requirements

• Close monitoring is essential during initial months of treatment for clinical worsening, suicidality, and unusual behavioral changes 3, 8
• This is particularly important during dose adjustments 3, 8

Discontinuation

• Taper slowly when discontinuing to avoid SSRI withdrawal syndrome 7, 3
• Avoid sudden cessation or rapid dose reduction 7

Drug Interactions

• Sertraline has minimal effects on cytochrome P450 enzymes, resulting in fewer drug-drug interactions compared to other SSRIs 3, 8
• Avoid in patients with bipolar depression due to risk of mania 7
• Exercise caution with concurrent serotonergic agents due to serotonin syndrome risk 7

Common Pitfalls to Avoid

• Do not start at doses higher than recommended - the 50 mg dose is already therapeutic for most patients with depression and OCD 2
• Do not increase doses more frequently than weekly intervals - steady state requires approximately 7 days 1
• Do not assume elderly patients need lower doses - age alone does not warrant dose reduction 5, 6
• Do not overlook the lower starting dose (25 mg) for anxiety disorders - this reduces early side effects in panic disorder, PTSD, and social anxiety disorder 1