What is the recommended starting dose of sertraline (selective serotonin reuptake inhibitor (SSRI)) for an adult patient with major depressive disorder and a history of suicidal attempts?

Sertraline Dosing for Major Depressive Disorder with History of Suicidal Attempts

Start sertraline at 50 mg once daily in the morning or evening for an adult with major depressive disorder and a history of suicidal attempts. 1

Initial Dosing Strategy

The FDA-approved starting dose for major depressive disorder is 50 mg once daily, which serves as both the initial and typically effective therapeutic dose. 1 This recommendation is based on the FDA drug label and represents the standard of care for initiating sertraline treatment in adults with MDD 1.

• The 50 mg starting dose is optimal when considering both efficacy and tolerability for most patients 2
• Sertraline may be administered at any time of day (morning or evening), given as a single daily dose 1, 2
• No dose adjustment is required based solely on age in elderly patients 3, 4

Critical Safety Monitoring in Patients with Suicidal History

Close monitoring for emergent suicidal ideation is essential, particularly during the first 1-2 months of treatment, as this represents the highest-risk period for suicide attempts. 5

• Patients younger than 24 years require especially vigilant monitoring for increased suicidal thoughts, as antidepressants carry a black box warning for this age group 5
• However, systematic review evidence (70 studies, n=18,526 patients) found no significant difference in suicidal ideation in adult men treated with antidepressants versus placebo (OR: 1.21; 95% CI: 0.84-1.74) 6
• In late-life depression specifically, sertraline was associated with significantly lower suicidal ideation scores than placebo during treatment, with no completed suicides or suicide attempts during clinical trials 7
• Begin monitoring patient status within 1-2 weeks of initiation for worsening depression, suicidal ideation, or behavioral changes 5

Dose Titration Protocol

If patients do not show adequate therapeutic response after 6-8 weeks at 50 mg daily, increase the dose in 50 mg increments at intervals of no less than 1 week, up to a maximum of 200 mg/day. 1, 2

• The 24-hour elimination half-life of sertraline necessitates waiting at least 1 week between dose changes 1, 2
• Patients were dosed in a range of 50-200 mg/day in clinical trials demonstrating effectiveness for MDD 1
• Allow 6-8 weeks at an adequate dose before determining treatment response and considering modification 5

Special Considerations for Suicidal Patients

Caution is particularly warranted when prescribing SSRIs to patients with comorbid depressive disorder associated with suicidal ideation, though the evidence does not support withholding treatment. 6

• A small increase in risk of suicidal ideation or suicide attempts was noted in patients under age 18, but not in adults 6
• For adults older than 65 years, antidepressant use appeared protective against suicidal behavior (OR: 0.06; 95% CI: 0.01 to 0.58) 6
• The risk for suicidal behaviors is highest in the first month of treatment when using SSRIs 6

Common Pitfalls to Avoid

• Do not start at 25 mg in adults with MDD - this lower dose is reserved for panic disorder, PTSD, and social anxiety disorder, not major depressive disorder 1
• Avoid sudden cessation or rapid dose reduction - this may precipitate SSRI withdrawal syndrome 6
• Do not discontinue prematurely - allow the full 6-8 weeks at therapeutic dose before declaring treatment failure 5
• Do not exceed 200 mg/day - this is the maximum recommended dose for MDD 1

Maintenance Treatment

Continue sertraline for several months or longer beyond response to the acute episode, as acute episodes of major depressive disorder require sustained pharmacologic therapy. 1

• Sertraline's antidepressant efficacy is maintained for periods of up to 44 weeks following 8 weeks of initial treatment at doses of 50-200 mg/day 1