What are the guidelines for prescribing sertraline (selective serotonin reuptake inhibitor) to an adult patient with major depressive disorder?

Prescribing Sertraline for Major Depressive Disorder in Adults

Start sertraline at 50 mg once daily, which is both the initial and optimal therapeutic dose for most adults with major depressive disorder. 1

Initial Dosing Strategy

• Begin with 50 mg once daily (morning or evening) for major depressive disorder 1
• This starting dose is the usually effective therapeutic dose when considering both efficacy and tolerability 2
• No dose titration is required for most patients, unlike other conditions where sertraline starts at 25 mg 1

When to Increase the Dose

• Wait at least 1 week before any dose adjustment due to sertraline's 24-hour elimination half-life 1
• If inadequate response after 2-4 weeks at 50 mg, increase in 50 mg increments 1
• Maximum dose is 200 mg/day 1
• Patients not responding to 50 mg may benefit from dose increases up to this maximum 1

Treatment Duration

• Continue for 4-9 months after satisfactory response for first-episode major depressive disorder 3
• Longer duration therapy is beneficial for patients with recurrent depression 3
• The American College of Physicians demonstrated efficacy in maintaining antidepressant response for up to 44 weeks following 8 weeks of acute treatment 1

Choosing Sertraline Over Other Antidepressants

The American College of Physicians recommends selecting between cognitive behavioral therapy or any second-generation antidepressant after discussing treatment effects, adverse effects, cost, accessibility, and patient preferences. 4

• All second-generation antidepressants are equally effective for treatment-naive patients 4
• Sertraline is preferred in older adults (≥65 years) along with citalopram, escitalopram, mirtazapine, venlafaxine, and bupropion 4, 5
• Avoid paroxetine and fluoxetine in older adults due to higher adverse effect rates 4, 5

Sertraline's Specific Advantages

• Lower rates of sexual dysfunction compared to paroxetine, though higher than bupropion 4
• Low potential for drug interactions at the cytochrome P450 enzyme level, particularly important in elderly patients on multiple medications 6, 7
• No dosage adjustment needed based on age alone 6, 7
• Well-tolerated in patients with cardiovascular disease, including post-myocardial infarction depression 8

Common Adverse Effects to Discuss

• Approximately 63% of patients on second-generation antidepressants experience at least one adverse effect 4
• Most common with sertraline: dry mouth, headache, diarrhea, nausea, insomnia, somnolence, constipation, dizziness, sweating 6, 7
• Nausea and vomiting are the most common reasons for discontinuation across all second-generation antidepressants 4
• Discontinuation due to adverse events occurs less frequently with sertraline (number needed to harm: 20-90) compared to tricyclic antidepressants (4-30) 4

When Sertraline Fails

• Approximately 38% of patients do not achieve treatment response during 6-12 weeks, and 54% do not achieve remission with any single antidepressant 5
• Switching to another second-generation antidepressant results in 25% achieving remission, with no significant difference between agents 4, 9
• Consider switching to bupropion, escitalopram, duloxetine, or venlafaxine extended release 4
• Augmentation with bupropion or buspirone shows no difference in response or remission rates 4

Special Considerations

• Screen for baseline QT interval with ECG in patients at high risk for arrhythmias before prescribing 8
• Monitor for drug-drug interactions periodically during therapy 8
• Sertraline has comparable cardiovascular safety to other SSRIs, with a preferable profile to citalopram in general cases 8
• Do not combine with MAOIs or start an MAOI without appropriate washout 5

Monitoring Response

• Assess response within 6-8 weeks of initiation 9
• Modify treatment if inadequate response at this timepoint 9
• Re-evaluate long-term usefulness periodically for patients on extended therapy 1