Should Sertraline Be Stopped in IBS?
No, sertraline should not be routinely stopped in someone with IBS, but it should be critically re-evaluated based on whether the patient has a concurrent mood disorder versus using it solely for gastrointestinal symptoms. 1
Clinical Decision Algorithm
If Sertraline Was Prescribed for IBS Gastrointestinal Symptoms Alone:
Consider switching to a tricyclic antidepressant (TCA) rather than continuing sertraline, as the American Gastroenterological Association suggests against using SSRIs for IBS treatment due to lack of efficacy for global symptoms and abdominal pain (RR 0.74; 95% CI 0.52-1.06, with the upper confidence interval suggesting possible symptom worsening). 1
TCAs are superior for IBS gastrointestinal symptoms, demonstrating clinically meaningful global symptom relief (RR 0.67; 95% CI 0.54-0.82) and abdominal pain relief (RR 0.76-0.94). 1
SSRIs increase gastrointestinal motility through increased synaptic serotonin concentration, which could theoretically worsen symptoms in some IBS patients, particularly those with diarrhea-predominant IBS. 1, 2
SSRIs do not significantly impact visceral sensation, which is a critical component of IBS pain pathophysiology. 1
If Sertraline Was Prescribed for Concurrent Mood Disorder (Depression/Anxiety):
Continue sertraline because SSRIs at therapeutic doses are the first-line treatment for mood disorders and are preferred over low-dose TCAs when moderate-to-severe depression or anxiety coexists with IBS. 1
Low-dose TCAs (used for IBS gastrointestinal symptoms) are inadequate to treat mood disorders, so switching from an SSRI to a TCA would leave the psychiatric condition undertreated. 1
The benefit in this scenario comes from treating the mood disorder, which can improve overall IBS symptom perception and well-being through effects on central pain processing and psychological symptom reduction. 1
Practical Implementation Strategy
For IBS-Diarrhea Patients on Sertraline:
Strongly consider switching to a TCA (such as amitriptyline 10 mg at bedtime, which has demonstrated efficacy in IBS-D), as TCAs reduce diarrhea through anticholinergic effects and prolonged gut transit time. 1, 2
Paroxetine specifically reduced orocaecal transit time in IBS patients, potentially worsening diarrhea symptoms. 2
For IBS-Constipation Patients on Sertraline:
The evidence is more nuanced: SSRIs increase gastrointestinal motility, which theoretically could help constipation, but clinical trials show no significant benefit for global IBS symptoms. 1
If no mood disorder exists, switch to a secondary amine TCA (desipramine or nortriptyline) which has lower anticholinergic effects and is better tolerated in IBS-C. 1
Critical Pitfalls to Avoid
Do not abruptly discontinue sertraline without assessing for underlying mood disorders, as untreated depression/anxiety significantly worsens IBS outcomes and quality of life. 1
Do not assume SSRIs are "doing nothing" in patients with psychiatric comorbidity—the improvement in well-being and quality of life may be clinically meaningful even without direct gastrointestinal symptom improvement. 3, 4
Recognize that neuromodulators take several weeks to work for IBS symptoms, so premature discontinuation may prevent assessment of true efficacy. 1
Be aware that SSRIs may improve patient satisfaction and quality of life without relieving primary gastrointestinal symptoms, representing what some describe as a "band-aid" approach rather than addressing core IBS pathophysiology. 3
Evidence Quality Considerations
The 2022-2023 AGA guidelines provide the strongest evidence base, with consistent recommendations across both IBS-C and IBS-D guidelines suggesting against SSRI use for IBS gastrointestinal symptoms specifically. 1 However, the 2023 Nature Reviews Gastroenterology & Hepatology guideline emphasizes that when moderate-to-severe mood disorders coexist, SSRIs at therapeutic doses should be the preferred initial choice over low-dose TCAs. 1
The meta-analysis by Ford et al. (2019) showed antidepressants overall reduce IBS symptoms (RR 0.66; 95% CI 0.57-0.76), but this benefit was similar for both TCAs and SSRIs, with significant heterogeneity in SSRI trials (I² = 49%). 4 This heterogeneity likely reflects the variable presence of psychiatric comorbidity across studies.