How to Taper Sertraline
Sertraline should be tapered using a hyperbolic reduction schedule where each new dose is approximately 90% of the previous dose, with reductions occurring no faster than every 1-2 weeks, and extending over several months to minimize withdrawal symptoms.
Tapering Protocol
Standard Tapering Schedule
Reduce sertraline by approximately 10% of the current dose (not the original dose) every 1-2 weeks, using a hyperbolic taper pattern where each reduction is 90% of the previous dose 1, 2.
For patients on sertraline long-term (months to years), plan for a taper duration of at least 2-4 months minimum, though some patients may require 6-12 months or longer 1.
The taper rate must be determined by the patient's ability to tolerate reductions, not by a rigid predetermined schedule 1.
Practical Dosing Strategy
Start with very small dose decreases initially (even 5-10% reductions) to address patient anxiety and build confidence in the tapering process 1.
Once the smallest commercially available dose is reached (typically 25 mg for sertraline), extend the interval between doses (e.g., every other day, then every third day) before complete discontinuation 1.
Pauses in the taper are acceptable and often necessary when withdrawal symptoms emerge—success is measured by durability and tolerability, not speed 1.
Managing Withdrawal Symptoms
Common Withdrawal Symptoms to Monitor
Watch for discontinuation symptoms including anxiety, irritability, insomnia, dizziness ("brain zaps"), headache, nausea, mood changes, and flu-like symptoms 1, 2.
These symptoms typically emerge within 1-3 days of dose reduction and may last 1-3 days with proper tapering, though they can persist longer if the taper is too rapid 1.
Pharmacological Support for Withdrawal
Consider trazodone 25-50 mg at bedtime for insomnia during the taper 1.
Consider gabapentin 100-300 mg daily (titrated as needed) for anxiety, irritability, and sensory symptoms 1.
Consider mirtazapine at low doses (7.5-15 mg) for combined insomnia and anxiety symptoms 3.
Use these adjunctive medications temporarily to ease the transition, not as long-term substitutes 1.
Critical Considerations and Pitfalls
What Never to Do
Never abruptly discontinue sertraline after more than a few days of use—this is unacceptable medical care and significantly increases withdrawal severity 1.
Never use a straight-line taper (e.g., reducing by the same absolute amount each time), as this creates disproportionately large reductions at lower doses 1, 2.
Never abandon the patient if tapering is difficult—maintain the therapeutic relationship and consider slowing the taper or pausing indefinitely at a lower maintenance dose 1.
When to Slow Down or Pause
If significant withdrawal symptoms emerge, pause the taper at the current dose for 1-4 weeks to allow accommodation 1.
For patients with previous failed taper attempts or severe withdrawal symptoms, extend each dose reduction interval to 3-4 weeks instead of 1-2 weeks 3.
Some patients may need to remain on a low maintenance dose indefinitely rather than complete discontinuation 1.
Monitoring and Follow-Up
Follow up with the patient at least monthly during the taper, with more frequent contact (weekly or biweekly) during difficult phases 1, 3.
Screen for unmasked anxiety, depression, or other psychiatric conditions that may emerge during tapering—distinguish these from withdrawal symptoms 1.
Educate patients that withdrawal symptoms are time-limited and manageable, and that the process requires patience and collaboration 1.
Special Populations
Elderly Patients
Use the same tapering principles but consider extending the time at each dose level, as elderly patients may be more sensitive to medication changes 1.
No specific dose adjustment is required for sertraline in elderly patients based on pharmacokinetics, but slower tapers may improve tolerability 4, 5.
Patients on Higher Doses
For patients on 150-200 mg daily, the taper will require proportionally longer duration—expect 6-12 months minimum 1, 3.
Consider reducing to 100 mg, then 75 mg, then 50 mg, then 37.5 mg (using liquid formulation or splitting tablets if needed), then 25 mg before final discontinuation 2.
Rationale for Hyperbolic Tapering
PET imaging studies demonstrate that SSRI effects on serotonin transporter occupancy follow a hyperbolic dose-response curve—linear dose reductions create exponentially increasing biological effects at lower doses 2.
Hyperbolic tapering (reducing by a percentage of the current dose) maintains consistent reductions in biological effect, minimizing withdrawal symptoms 2.
Traditional guideline recommendations for 2-4 week tapers to minimum therapeutic doses show minimal benefit over abrupt discontinuation and are often not tolerated by patients 2.