What is the recommended dosage and treatment regimen for sertraline (selective serotonin reuptake inhibitor) in treating depression and anxiety disorders?

Sertraline Dosing and Treatment Regimen

Starting Dose

For depression and most anxiety disorders in adults, start sertraline at 50 mg once daily, which is both the initial and typically effective therapeutic dose. 1

For panic disorder, PTSD, and social anxiety disorder specifically, the FDA-approved regimen begins at 25 mg once daily for one week, then increases to 50 mg once daily. 1 However, starting with 25 mg is primarily to minimize initial anxiety or agitation that can occur with SSRIs, not because it provides therapeutic benefit. 2

Dose Titration

• Increase the dose in 50 mg increments at intervals of no less than 1 week if patients do not respond adequately to 50 mg daily. 1
• The therapeutic range is 50-200 mg/day, with a maximum dose of 200 mg/day. 1
• Most patients respond optimally at 50 mg daily without requiring dose escalation, as this dose balances efficacy and tolerability. 3, 4
• Higher doses may increase efficacy in non-responders but also increase adverse effects. 5, 2

Administration Timing

• Administer once daily, either morning or evening—timing does not affect efficacy. 1
• In pediatric patients at low doses, twice-daily dosing may be required. 2

Expected Response Timeline

• Statistically significant improvement occurs within 2 weeks, clinically significant improvement by week 6, and maximal improvement by week 12 or later. 2
• This timeline supports starting at 50 mg and waiting at least 6 weeks before concluding inadequate response. 2
• Avoid exceeding the optimal dose by titrating too quickly before maximal benefit is achieved. 2

Maintenance Treatment Duration

• Continue treatment for at least 4-12 months for an initial depressive episode. 6
• For recurrent depression, prolonged treatment beyond 12 months is beneficial. 6
• Anxiety disorders typically require continuing therapy, as symptoms usually return upon discontinuation. 2
• Sertraline maintains efficacy for up to 44 weeks in depression and 28 weeks in PTSD and OCD. 1

Special Populations

Elderly Patients

• No dosage adjustment is needed based on age alone—use the same 50 mg starting dose. 3, 7
• Sertraline is preferred in elderly patients due to low anticholinergic effects and minimal drug interactions compared to tricyclics and some other SSRIs. 7

Pediatric Patients (OCD only FDA-approved indication)

• Children ages 6-12: Start at 25 mg once daily. 1
• Adolescents ages 13-17: Start at 50 mg once daily. 1
• Maximum dose 200 mg/day, with dose adjustments at minimum 1-week intervals. 1

Critical Safety Monitoring

• All patients through age 24 require close monitoring for suicidal thinking and behavior, especially during the first months and after dose changes (FDA boxed warning). 2
• The number needed to harm is 143 versus number needed to treat of 3, supporting careful but confident use. 2
• Monitor for serotonin syndrome when combining with other serotonergic drugs, particularly within 24-48 hours of combination. 2

Common Adverse Effects

• Nausea, diarrhea, headache, insomnia, dizziness, dry mouth, and somnolence typically emerge within the first few weeks. 2, 7
• Sexual dysfunction occurs in approximately 40% of patients on SSRIs. 6
• Sertraline has lower risk of discontinuation syndrome compared to paroxetine but still requires gradual tapering when stopping. 6, 2

Drug Interactions

• Contraindicated with MAOIs—allow at least 14 days between discontinuing an MAOI and starting sertraline, and vice versa. 1
• Sertraline has low potential for cytochrome P450 interactions compared to fluoxetine, fluvoxamine, and paroxetine, but may still interact with CYP2D6 substrates. 6
• Do not start sertraline in patients receiving linezolid or IV methylene blue due to serotonin syndrome risk. 1

Combination Therapy

• For pediatric anxiety disorders (social anxiety, generalized anxiety, separation anxiety, panic disorder), combination treatment with CBT plus sertraline is superior to monotherapy. 2

Clinical Pitfalls to Avoid

• Do not start at 25 mg for depression or OCD in adults—this is subtherapeutic and delays response. 6, 1
• Do not increase doses more frequently than weekly intervals due to sertraline's 24-hour half-life. 1
• Do not abruptly discontinue—taper gradually to minimize discontinuation syndrome symptoms (dizziness, fatigue, nausea, sensory disturbances). 2
• Approximately 38% of patients do not achieve response and 54% do not achieve remission during 6-12 weeks, necessitating close monitoring and potential medication adjustments. 6