What is the recommended starting dose of sertraline (selective serotonin reuptake inhibitor - SSRI) for anxiety?

Starting Dose of Sertraline for Anxiety

For adults with anxiety disorders (panic disorder, PTSD, social anxiety disorder), start sertraline at 25 mg once daily for one week, then increase to 50 mg once daily. 1

FDA-Approved Dosing by Anxiety Disorder Type

Panic Disorder, PTSD, and Social Anxiety Disorder (Adults)

• Initial dose: 25 mg once daily 1
• After 1 week: Increase to 50 mg once daily 1
• The therapeutic range is 50-200 mg/day, with dose adjustments made at intervals of no less than 1 week due to sertraline's 24-hour elimination half-life 1
• Patients not responding to 50 mg may benefit from dose increases up to a maximum of 200 mg/day 1

Generalized Anxiety Disorder (Adults)

• While not FDA-approved for GAD specifically, clinical trial data supports starting at 50 mg/day with flexible dosing up to 150 mg/day 2
• Significant improvement over placebo was demonstrated at week 4, with 63% response rate versus 37% for placebo 2

Pediatric Dosing for Anxiety (Ages 6-17)

For children and adolescents with anxiety disorders:

• Children (ages 6-12): Start at 25 mg once daily 3, 1
• Adolescents (ages 13-17): Start at 50 mg once daily 3, 1
• Maximum dose: 200 mg/day for both age groups 1
• Parental oversight of medication regimens is paramount 3

Critical Titration Strategy

Test Dose Approach

• Consider starting with a subtherapeutic dose (even lower than 25 mg) in patients prone to anxiety or agitation, as SSRIs can initially cause these symptoms 3, 4
• This is particularly important because an initial adverse effect of SSRIs can be anxiety or agitation 3

Dose Adjustment Intervals

• For sertraline (shorter half-life SSRI), dose adjustments can be made at approximately 1-2 week intervals when titrating 3, 4
• Faster up-titration may be indicated for more severe anxiety presentations, though higher doses can be associated with more adverse effects 3, 4
• It is not clear that dose of medication is related to magnitude of response 3

Response Timeline and Monitoring

Expected Response

• Statistically significant improvement may occur within 2 weeks 4
• Clinically significant improvement typically by week 6 4
• Maximal improvement by week 12 or later, supporting slow up-titration to avoid exceeding the optimal dose 4

Safety Monitoring

• Monitor closely for suicidal thinking and behavior, especially in the first months of treatment and following dosage adjustments (pooled absolute rate: 1% for antidepressants versus 0.2% for placebo; number needed to harm = 143) 4
• Watch for behavioral activation/agitation, hypomania, mania, seizures, abnormal bleeding, and serotonin syndrome 4
• Most adverse effects emerge within the first few weeks of treatment 4
• Systematic assessment using standardized symptom rating scales can supplement clinical evaluation 3, 4

Administration Considerations

• Can be administered at any time of day (morning or evening) 4, 1
• At low doses, some patients may require twice-daily dosing 4
• No dose adjustment needed for renal impairment 4
• Reduced dose recommended for hepatic disease 4

Common Pitfalls to Avoid

• Never combine with MAOIs due to serotonin syndrome risk; allow at least 14 days between discontinuing an MAOI and starting sertraline 4, 1
• Do not abruptly discontinue - sertraline is associated with discontinuation syndrome (dizziness, fatigue, myalgias, headaches, nausea, insomnia, sensory disturbances); taper gradually 3, 4
• Exercise caution when combining with other serotonergic agents (triptans, tramadol, fentanyl) due to serotonin syndrome risk 4
• Monitor for abnormal bleeding when prescribed with anticoagulants or antiplatelet agents (warfarin, aspirin, NSAIDs) 4

Clinical Trial Evidence Supporting Efficacy

• Panic disorder: Effective at 50-175 mg/day range, with 82% reduction in panic attack frequency in high-risk patients 5, 6
• Social anxiety disorder: 53% response rate versus 29% for placebo at doses up to 200 mg/day, with mean reductions of 32.6% on social phobia measures 7
• Generalized anxiety disorder: Significantly greater improvement than placebo on all efficacy measures, well tolerated with only 8% dropout rate versus 10% for placebo 2