What is the typical starting dose of sertraline (selective serotonin reuptake inhibitor) for an adult patient with depression or anxiety?

Starting Dose for Sertraline

For adults with depression or anxiety disorders, start sertraline at 50 mg once daily for major depressive disorder and obsessive-compulsive disorder, or 25 mg once daily for panic disorder, PTSD, and social anxiety disorder (increasing to 50 mg after one week). 1

Standard Adult Dosing by Indication

Depression and OCD

• Initial dose: 50 mg once daily 1
• Can be administered at any time of day (morning or evening) 2, 3
• This starting dose is both the usually effective therapeutic dose and the optimal dose when considering efficacy and tolerability for most patients 4

Panic Disorder, PTSD, and Social Anxiety Disorder

• Initial dose: 25 mg once daily for one week 1
• Then increase to 50 mg once daily 1
• This lower starting dose helps minimize initial anxiety or agitation that SSRIs can cause 2, 3

Pediatric Dosing (Ages 6-17)

For OCD (Only FDA-Approved Pediatric Indication)

• Children (ages 6-12): Start at 25 mg once daily 1, 5
• Adolescents (ages 13-17): Start at 50 mg once daily 1, 5
• Parental oversight of medication regimens is paramount 2, 3

For Anxiety Disorders (Off-Label in Pediatrics)

• Consider starting with a subtherapeutic "test dose" (even lower than 25 mg) in patients prone to anxiety or agitation, as SSRIs can initially worsen these symptoms 2, 5

Special Population Considerations

Elderly Patients

• No age-based dose adjustment required 6
• Start at standard adult dose of 50 mg daily for depression 2, 6
• For elderly patients with Alzheimer's disease and depression, may start at 25-50 mg per day 2
• Sertraline is preferred in elderly patients due to lack of anticholinergic effects and minimal drug interactions 3, 6

Hepatic Impairment

• Reduced dose is recommended 3, 5

Renal Impairment

• No dose adjustment needed 3, 5

Titration Strategy and Timeline

Dose Adjustment Intervals

• Do not increase dose more frequently than once weekly due to sertraline's 24-hour elimination half-life 1
• For shorter half-life SSRIs like sertraline, dose adjustments can be made at approximately 1-2 week intervals 3
• Increase in 50 mg increments if inadequate response after 2-4 weeks at current dose 3, 4
• Maximum dose: 200 mg/day 1

Expected Response Timeline

• Statistically significant improvement may occur within 2 weeks 2, 3
• Clinically significant improvement typically by week 6 2, 3
• Maximal improvement by week 12 or later 2, 3
• This logarithmic response model supports slow up-titration to avoid exceeding the optimal dose 2

Critical Safety Monitoring

First Weeks of Treatment

• Monitor closely for suicidal thinking and behavior, especially in the first months and following dose adjustments 2, 3
• Pooled absolute rate for suicidal ideation: 1% for antidepressants vs. 0.2% for placebo (Number Needed to Harm = 143) 2, 3
• All SSRIs carry a boxed warning for suicidal thinking and behavior through age 24 years 2

Behavioral Activation/Agitation

• May occur early in treatment or with dose increases, particularly in younger children and anxiety-prone patients 2, 3
• More common in anxiety disorders compared to depressive disorders 2
• If this occurs, consider dose reduction or slower titration 2

Common Adverse Effects (Emerge Within First Few Weeks)

• Nausea, diarrhea, headache, insomnia, dizziness, sexual dysfunction, sweating 2, 3
• Most adverse effects are dose-related and improve with time 2

Important Contraindications and Drug Interactions

Absolute Contraindications

• Never combine with MAOIs due to risk of serotonin syndrome 2, 3, 5
• Allow at least 14 days between discontinuing an MAOI and starting sertraline 5

Significant Drug Interactions

• Exercise caution with other serotonergic agents (triptans, tramadol, fentanyl) due to serotonin syndrome risk 3
• Monitor for abnormal bleeding when combined with anticoagulants or antiplatelet agents (warfarin, aspirin, NSAIDs) 3
• Sertraline has minimal cytochrome P450 interactions compared to other SSRIs 2, 3, 6

Administration Considerations

Dosing Frequency

• Most patients: Once daily dosing 1, 4
• At low doses (below 50 mg): Some patients may require twice-daily dosing due to shorter half-life 2, 3
• This is particularly relevant in children and adolescents on 25 mg doses 2

Common Pitfalls to Avoid

• Never start at higher doses (increases risk of deliberate self-harm and suicide-related events) 2
• Never abruptly discontinue - sertraline is associated with discontinuation syndrome (dizziness, fatigue, myalgias, headaches, nausea, insomnia, sensory disturbances) 2, 3, 5
• Always taper gradually over minimum 2-4 weeks, or several months for long-term therapy 3
• Do not increase dose too quickly - allow adequate trial duration (at least 2-4 weeks) at each dose before increasing 3
• Do not mistake inadequate trial duration for treatment failure - requires 8 weeks at optimal dose for adequate trial 3