Sertraline Dosing and Treatment Protocol
Start sertraline at 50 mg once daily for adults with major depressive disorder and OCD, or 25 mg once daily for panic disorder, PTSD, and social anxiety disorder (increasing to 50 mg after one week), with dose adjustments at weekly intervals up to a maximum of 200 mg/day based on therapeutic response. 1
Initial Dosing by Indication
Adults
- Major Depressive Disorder and OCD: Begin at 50 mg once daily 1
- Panic Disorder, PTSD, and Social Anxiety Disorder: Start at 25 mg once daily, then increase to 50 mg after one week 1
- PMDD: Initiate at 50 mg/day, either daily throughout the menstrual cycle or limited to the luteal phase 1
- Administration timing: Can be given morning or evening—no difference in efficacy 2
Pediatric Patients (OCD only)
- Children (ages 6-12): Start at 25 mg once daily 1
- Adolescents (ages 13-17): Start at 50 mg once daily 1
- For adolescent depression: Start at 25 mg once daily, with increments of 12.5-25 mg, effective dose 50 mg, maximum 200 mg 3
Dose Titration Strategy
Increase doses at intervals of no less than 1 week, as sertraline has a 24-hour elimination half-life. 1
- Standard increments: 50 mg increases for adults 1
- Adolescent increments: 12.5-25 mg increases 3
- Therapeutic range: 50-200 mg/day across all indications 2
- For shorter half-life SSRIs like sertraline, dose adjustments can be made at approximately 1-2 week intervals 2
Special Titration Considerations
- Test dose approach: Consider starting with subtherapeutic doses in patients prone to anxiety or agitation, as SSRIs can initially worsen these symptoms 2
- Faster titration: May be indicated for severe presentations, though higher doses associate with more adverse effects 2
- Low-dose sertraline: Some patients may require twice-daily dosing at low doses 3, 2
Response Timeline and Assessment
Expect statistically significant improvement within 2 weeks, clinically significant improvement by week 6, and maximal improvement by week 12 or later—this supports slow up-titration to avoid exceeding optimal dose. 2
- Initial assessment: Within 1-2 weeks of initiation to monitor adverse events and suicidality 3
- Inadequate response threshold: If no adequate response within 6-8 weeks, modify treatment 3
- Dose optimization: Patients not responding to 50 mg may benefit from increases up to 200 mg/day 1
Monitoring Requirements
Critical Safety Monitoring
Monitor closely for suicidal thinking and behavior, especially in the first months of treatment and following dosage adjustments—the pooled absolute rate for suicidal ideation is 1% for antidepressants versus 0.2% for placebo (NNH = 143). 3, 2
- FDA black-box warning: All pediatric patients require close observation for clinical worsening, suicidality, and unusual behavior changes 3
- Monitoring frequency: Regular contact (in-person or telephone) within 1-2 weeks of initiation and after dose changes 3
- Higher risk period: First 1-2 months of treatment 3
Adverse Event Surveillance
Most adverse effects emerge within the first few weeks of treatment and are dose-related. 3, 2
Common adverse effects to monitor: 3, 2, 4, 5
- Gastrointestinal: nausea, diarrhea, dry mouth, constipation
- CNS: headache, dizziness, insomnia, somnolence
- Other: sweating, tremor, sexual dysfunction
Serious adverse effects requiring vigilance: 3, 2
- Behavioral activation/agitation: More common in younger children and anxiety disorders; occurs early in treatment or with dose increases
- Mania/hypomania: May appear later than behavioral activation and persist after discontinuation
- Serotonin syndrome: Risk when combining serotonergic medications; symptoms within 24-48 hours
- Abnormal bleeding: Especially with concomitant NSAIDs or aspirin
- Seizures: Use cautiously in patients with seizure history
Maintenance Treatment Duration
Major depressive disorder requires several months or longer of sustained therapy beyond acute response—sertraline efficacy is maintained for up to 44 weeks following initial 8-week treatment. 1
- PTSD: Efficacy maintained for 28 weeks following 24 weeks of treatment 1
- Social Anxiety Disorder: Efficacy maintained for 24 weeks following 20 weeks of treatment 1
- OCD and Panic Disorder: Require several months or longer of sustained therapy 1
- Periodic reassessment: Determine ongoing need for maintenance treatment and maintain patients on lowest effective dose 1
Discontinuation Protocol
Taper sertraline slowly when discontinuing due to risk of discontinuation syndrome (dizziness, fatigue, myalgias, headaches, nausea, insomnia, sensory disturbances). 3, 2
- Never abrupt cessation: All SSRIs should be slowly tapered 3
- Sertraline-specific risk: Associated with discontinuation symptoms due to shorter half-life 2
Special Population Considerations
Elderly Patients
- No age-based dose adjustment required 4, 5, 6
- Alzheimer's disease with depression: Start 25-50 mg/day, maximum 200 mg/day 2
- Advantages in elderly: Low potential for drug interactions via cytochrome P450 system, fewer anticholinergic effects than TCAs 2, 4, 5
Drug Interactions
- Absolute contraindication: MAOIs due to serotonin syndrome risk 3, 2
- Minimal cytochrome P450 effects: Fewer drug-drug interactions compared to other SSRIs 2, 4, 5
- Caution with serotonergic drugs: Risk of serotonin syndrome when combined 2
Optimal Dosing Evidence
The 50 mg daily dose is the optimal dose when considering both efficacy and tolerability for most patients—it is as effective as higher dosages with fewer side effects and therapy discontinuations. 7, 6, 8