Sertraline Withdrawal Protocol
Sertraline should be tapered gradually over a minimum of 6-10 weeks for patients on long-term therapy, reducing the dose by 25-50 mg every 1-2 weeks, with slower tapers extending over several months for patients who have been on treatment for more than 4-12 months. 1, 2
Why Gradual Tapering is Essential
Abrupt discontinuation of sertraline causes withdrawal syndrome in a significant proportion of patients, with symptoms typically emerging within 24-48 hours and persisting for 2-3 weeks. 3, 4 The syndrome includes:
- Somatic symptoms: dizziness, vertigo, sensory disturbances (paresthesias), nausea, fatigue, myalgias, flu-like symptoms, and sleep disturbances 5, 4, 6
- Psychological symptoms: anxiety, irritability, crying spells, confusion, vivid dreams, and mood changes 5, 4, 6
Sertraline, despite having a moderate half-life of approximately 26 hours, still produces withdrawal symptoms that require gradual tapering. 6, 7 Research demonstrates that 17.2% of patients on shorter half-life SSRIs experience withdrawal symptoms even with slow tapers. 6
Recommended Tapering Schedule
For Standard Long-Term Therapy (>3 months)
Start with 25-50 mg dose reductions every 1-2 weeks, monitoring closely for withdrawal symptoms at each step. 1, 2 For example, if a patient is on sertraline 150 mg:
- Week 0-2: 150 mg → 100-125 mg 2
- Week 2-4: 100-125 mg → 75-100 mg 2
- Week 4-6: 75-100 mg → 50 mg 2
- Week 6-8: 50 mg → 25 mg 2
- Week 8-10: 25 mg → discontinue 2
For Extended Long-Term Therapy (>12 months) or High-Risk Patients
Slower tapers extending over several months are necessary, potentially using 10% reductions of the current dose at each step rather than fixed mg amounts. 1, 8 This hyperbolic tapering approach reduces the biological effect at serotonin transporters in a more linear manner, minimizing withdrawal symptoms. 8
High-risk patients requiring especially slow tapers include: 1
- Those with previous severe withdrawal symptoms
- Patients with comorbid anxiety disorders
- Those on treatment duration >12 months
- Patients with history of poor medication compliance
Managing Withdrawal Symptoms During Taper
If moderate to severe withdrawal symptoms emerge, immediately reinstitute the previous dose and hold for an additional 1-2 weeks before attempting further reduction. 1 Do not push through severe symptoms.
For mild symptoms: Reassure the patient that symptoms are transient and typically resolve within 2-3 weeks. 5, 4
For severe or intolerable symptoms: Resume the previously prescribed dose, then decrease at a more gradual rate (e.g., 10% reductions instead of 25-50 mg reductions). 1, 2
Critical Monitoring Requirements
Establish weekly contact (phone or in-person) during the first month of tapering, then monthly thereafter until complete discontinuation. 9 Monitor specifically for:
- Withdrawal symptoms: dizziness, sensory disturbances, mood changes 2
- Return of original psychiatric symptoms: distinguish from withdrawal 1
- Suicidal ideation: particularly in younger patients 1
Before initiating taper, establish a collaborative plan that includes clear explanation of why gradual tapering is necessary, discussion of potential withdrawal symptoms, and agreement on the taper schedule. 1
Common Pitfalls to Avoid
Do NOT use rapid 2-4 week tapers as suggested in older guidelines—these show minimal benefit over abrupt discontinuation and are often not tolerated by patients on long-term therapy. 2, 8 The American College of Physicians explicitly states that 10-14 day tapers are inadequate for long-term therapy. 2
Do NOT stop at therapeutic minimum doses (50 mg for sertraline) and then abruptly discontinue—taper to much lower doses (25 mg or less) before complete cessation. 8
Do NOT mistake withdrawal symptoms for relapse of depression—this leads to unnecessary long-term medication continuation. 8, 5 Withdrawal symptoms typically begin within 24-48 hours of dose reduction, whereas relapse develops more gradually over weeks. 4
Do NOT use benzodiazepines to treat withdrawal symptoms—they are ineffective for SSRI discontinuation syndrome. 6 The only effective treatment is restarting the SSRI. 4, 6
Special Considerations
For patients switching to another antidepressant (cross-tapering), maintain sertraline at the current dose while starting the new medication at low doses, then begin gradual sertraline taper only after confirming tolerability of the new agent. 9
Patient education is paramount: Explain that withdrawal symptoms do not indicate addiction, are time-limited, and can be managed by slowing the taper. 4 Poor treatment compliance and lack of patient education are risk factors for severe withdrawal. 4
The taper rate is ultimately determined by the patient's ability to tolerate dose reductions—some patients require tapers extending over 6-12 months. 1, 8