What is the typical starting dose of sertraline (Selective Serotonin Reuptake Inhibitor - SSRI)?

Sertraline Starting Dose

The standard starting dose of sertraline is 50 mg once daily for adults, administered after an initial week at 25 mg/day, though many clinicians begin directly at 50 mg/day for most indications. 1

Adult Dosing by Indication

Major Depressive Disorder, OCD, Panic Disorder, PTSD, and Social Anxiety Disorder

• Begin with 25 mg once daily for one week, then increase to 50 mg once daily as the initial therapeutic dose 1
• The 50 mg/day dose is both the starting therapeutic dose and the optimal dose for most patients when balancing efficacy and tolerability 2
• The therapeutic range spans 50-200 mg/day across all approved indications, with dose increases considered after 2-4 weeks if response is inadequate 3
• Dose adjustments should occur at intervals of no less than 1 week, given sertraline's 24-hour elimination half-life 1

Premenstrual Dysphoric Disorder (PMDD)

• Start at 50 mg/day, either daily throughout the menstrual cycle or limited to the luteal phase 1
• Patients may benefit from dose increases in 50 mg increments up to 150 mg/day (continuous dosing) or 100 mg/day (luteal phase dosing) 1

Pediatric Dosing

Children (Ages 6-12) with OCD

• Start with 25 mg once daily 4, 5, 1
• May titrate up to a maximum of 200 mg/day based on response, with dose changes at weekly intervals 1
• Lower body weights should be considered when advancing doses to avoid excess dosing 1

Adolescents (Ages 13-17) with OCD

• Start with 50 mg once daily 4, 5, 1
• Titration follows the same principles as for younger children, with weekly dose adjustments as needed 1

Special Population Considerations

Elderly Patients

• No dose adjustment needed based on age alone; start with the standard 50 mg/day dose 3, 6
• Sertraline is preferred in elderly patients due to lack of anticholinergic effects and minimal cytochrome P450 interactions 3
• No dosage adjustments are warranted for elderly patients solely based on age 7, 6

Patients with Alzheimer's Disease and Depression

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

Hepatic Impairment

• Use a reduced dose in patients with hepatic disease 3

Renal Impairment

• No dose adjustment needed 3

Titration Strategy and Monitoring

Dose Escalation Approach

• For patients prone to anxiety or agitation, consider starting with a subtherapeutic dose (25 mg), as SSRIs can initially worsen these symptoms 3
• Dose adjustments can be made at approximately 1-2 week intervals when titrating 3
• Faster titration may be indicated for more severe presentations, though higher doses carry increased risk of adverse effects 3

Response Timeline

• Statistically significant improvement may occur within 2 weeks 3
• Clinically significant improvement typically emerges by week 6 3
• Maximal improvement occurs by week 12 or later, supporting slow up-titration to avoid exceeding the optimal dose 3

Administration Details

• Sertraline can be administered at any time of day (morning or evening) 3, 1
• Once-daily dosing is standard, though some patients on low doses may require twice-daily dosing 3

Critical Safety Monitoring

Early Treatment Period

• Monitor closely for suicidal thinking and behavior, especially in the first months of treatment and following dose adjustments 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

Discontinuation Considerations

• Never abruptly discontinue sertraline; taper gradually to avoid discontinuation syndrome 3, 4
• Discontinuation syndrome includes dizziness, fatigue, myalgias, headaches, nausea, insomnia, and sensory disturbances 3

Drug Interactions

• Exercise caution with other serotonergic agents (triptans, tramadol, fentanyl) due to serotonin syndrome risk 3
• Monitor for abnormal bleeding when combined with anticoagulants or antiplatelet agents (warfarin, aspirin, NSAIDs) 3
• Contraindicated with MAOIs 3

Common Pitfalls to Avoid

• Avoid starting at doses higher than 50 mg/day in most patients, as this increases adverse effects without improving efficacy 2
• Do not increase doses more frequently than weekly intervals, as sertraline's 24-hour half-life requires time to reach steady state 1
• Do not assume treatment failure before 6-12 weeks at an adequate dose, as maximal improvement takes time 3