What's the next step for a 42-year-old patient with improved anxiety and mood on sertraline (selective serotonin reuptake inhibitor) 50mg for 2 weeks, but experiencing insomnia and jaw tension?

Management of SSRI-Induced Insomnia and Jaw Tension

Continue sertraline at the current dose while addressing the side effects symptomatically, as both insomnia and bruxism (jaw tension) are common early adverse effects that typically emerge within the first few weeks of SSRI treatment and often improve with continued use. 1

Understanding the Clinical Context

Your patient is experiencing two well-documented SSRI side effects at 2 weeks of treatment:

• Insomnia and bruxism (jaw tension/teeth grinding) are recognized adverse effects of SSRIs that commonly emerge within the first few weeks of treatment 1
• The patient has already achieved therapeutic benefit (improved anxiety and mood), which is actually earlier than the typical 6-week timeline for clinically significant improvement 1, 2
• At only 2 weeks, you are still within the early treatment window where side effects are most common but often transient 1

Recommended Management Strategy

First-Line Approach: Watchful Waiting with Symptom Management

Do not discontinue or reduce the sertraline dose at this point, as the patient is responding therapeutically and most adverse effects decrease in frequency with continued treatment 1

For the insomnia:

• Consider short-term use of a sedating agent if sleep disturbance is severe 1
• Low-dose trazodone (50 mg) is commonly used off-label for SSRI-induced insomnia, though formal guidelines suggest against it as monotherapy for insomnia 1
• Alternatively, consider eszopiclone, zolpidem, or zaleplon for sleep onset issues 1
• Reassure the patient that insomnia often improves with continued SSRI treatment 1

For the jaw tension/bruxism:

• Low-dose quetiapine (25-50 mg daily) has demonstrated effectiveness for SSRI-induced bruxism through its 5-HT2 receptor antagonism 3
• This is a well-tolerated adjunctive strategy that addresses both the bruxism and can help with sleep 3
• Patients typically report improvement within a few days of starting quetiapine 3

Timing Considerations

The 2-week mark is too early to make major medication changes for several critical reasons:

• Statistically significant improvement occurs within 2 weeks, but clinically significant improvement typically requires 6 weeks, with maximal benefit at 12 weeks or later 1, 2
• Most adverse effects are transient and decrease with continued treatment 1
• Changing medications now would restart the therapeutic timeline and potentially lose the gains already achieved 1

Alternative Dosing Strategy (If Side Effects Are Intolerable)

If the patient cannot tolerate the side effects even with adjunctive management:

• Consider splitting the 50 mg dose to twice-daily dosing (25 mg BID), as sertraline at low doses may require twice-daily administration due to its shorter half-life compared to other SSRIs 1, 2
• This can reduce peak-related side effects while maintaining therapeutic levels 1, 2
• Take the second dose earlier in the day (not at bedtime) to minimize insomnia 2

Monitoring and Follow-Up

Schedule close follow-up within 1-2 weeks to reassess:

• Persistence or resolution of insomnia and bruxism 1
• Continued therapeutic benefit for anxiety and mood 1
• Emergence of any concerning symptoms like behavioral activation, agitation, or suicidal ideation (particularly important given the boxed warning for patients under age 24) 1

Critical Safety Considerations

Monitor for behavioral activation/agitation, which can manifest as motor restlessness, insomnia, impulsiveness, or disinhibited behavior—this is more concerning than simple insomnia and may require dose reduction 1

Distinguish between:

• Simple insomnia (a common, often transient side effect) 1
• Behavioral activation (restlessness, agitation, impulsiveness—requires intervention) 1
• True mania/hypomania (rare, may appear later in treatment and persist after dose reduction) 1

What NOT to Do

Do not abruptly discontinue sertraline, as it is associated with discontinuation syndrome characterized by dizziness, fatigue, myalgias, headaches, nausea, and sensory disturbances 2

Do not increase the dose yet—the patient is already responding at 50 mg, and higher doses are associated with more adverse effects 1

Do not switch SSRIs at this early stage unless side effects are truly intolerable despite adjunctive management, as you would lose the therapeutic gains already achieved 1