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

Sertraline Dosing in Adults

For most adults with depression, OCD, panic disorder, PTSD, or social anxiety disorder, start sertraline at 50 mg once daily, with the option to titrate up to 200 mg daily based on response after at least one week at each dose. 1

Standard Initial Dosing

• Major Depressive Disorder and Obsessive-Compulsive Disorder: Begin with 50 mg once daily 1
• Panic Disorder, PTSD, and Social Anxiety Disorder: Start at 25 mg once daily for one week, then increase to 50 mg once daily 1
• Premenstrual Dysphoric Disorder: Initiate at 50 mg daily, either throughout the menstrual cycle or limited to the luteal phase 1

The FDA label establishes 50 mg as both the starting and typically effective therapeutic dose for most indications, which aligns with the American Academy of Family Physicians guidance 2, 3, 1. This dose represents the optimal balance between efficacy and tolerability for the majority of patients 4.

Titration Strategy

• Dose increases should occur at intervals of no less than 1 week, given sertraline's 24-hour elimination half-life 1
• For inadequate response at 50 mg, increase in 50 mg increments up to a maximum of 200 mg daily 1
• The therapeutic range across all approved indications is 50-200 mg/day 3
• Faster titration may be appropriate for severe presentations, though higher doses carry increased risk of adverse effects 3

The American Academy of Child and Adolescent Psychiatry recommends dose adjustments at approximately 1-2 week intervals for shorter half-life SSRIs like sertraline 3. Clinical improvement typically becomes statistically significant within 2 weeks, with maximal benefit by week 12 or later, supporting gradual up-titration 3.

Administration Timing

• Sertraline can be administered at any time of day—morning or evening—as a single daily dose 3, 1, 4
• At very low doses, some patients may require twice-daily dosing 3

Special Population Considerations

Elderly Patients

• No dosage adjustment is required based on age alone 5, 6
• Start at the standard adult dose of 50 mg daily 5, 6
• Sertraline is preferred over tricyclic antidepressants in elderly patients due to lack of anticholinergic effects 2, 5
• The drug has minimal cytochrome P450 interactions, making it particularly suitable for elderly patients on multiple medications 5, 6

Patients with Alzheimer's Disease and Depression

• Initial dose: 25-50 mg daily, with a maximum of 200 mg daily 3
• Sertraline is well-tolerated and has fewer drug-drug interactions compared to other SSRIs in this population 3

Hepatic or Renal Impairment

• Reduce dose in hepatic disease 2
• No dose adjustment needed for renal impairment 2

Monitoring and Safety

• Monitor closely for suicidal thinking and behavior, especially in the first months of treatment and after dose changes 3
• The pooled absolute rate for suicidal ideation is 1% for antidepressants versus 0.2% for placebo (number needed to harm: 143) 3
• Watch for behavioral activation/agitation, hypomania, mania, seizures, abnormal bleeding, and serotonin syndrome 3
• Most adverse effects emerge within the first few weeks and are dose-related 3

Common Adverse Effects

• Typical side effects include sweating, tremors, nervousness, insomnia or somnolence, dizziness, gastrointestinal disturbances, and sexual dysfunction 3
• In elderly patients, the most frequent adverse events are dry mouth, headache, diarrhea, nausea, insomnia, somnolence, constipation, dizziness, sweating, and taste abnormalities 5, 6

Maintenance Treatment

• Continue treatment for 4-12 months after a first episode of major depressive disorder 2
• Patients with recurrent depression may benefit from prolonged treatment 2
• Sertraline's antidepressant efficacy is maintained for periods up to 44 weeks following initial treatment 1
• Periodically reassess patients to determine the need for continued maintenance treatment 1

Discontinuation

• Taper gradually when discontinuing to avoid discontinuation syndrome (dizziness, fatigue, myalgias, headaches, nausea, insomnia, sensory disturbances) 3
• Sertraline is contraindicated with MAOIs due to serotonin syndrome risk 3

Key Clinical Pitfalls

• Avoid dose changes more frequently than weekly intervals—sertraline requires approximately 7 days to reach steady state 1, 7
• Do not confuse sertraline with paroxetine or fluoxetine when treating elderly patients; sertraline has fewer drug interactions and no need for age-based dose reduction 2, 5
• Ensure parental oversight in pediatric patients if prescribing for OCD (ages 6-17) 3