What is the starting dose of sertraline (selective serotonin reuptake inhibitor) for a general adult population?

Starting Dose of Sertraline

The starting dose of sertraline for most adults is 50 mg once daily for major depressive disorder and obsessive-compulsive disorder, while panic disorder, PTSD, and social anxiety disorder should begin at 25 mg once daily for one week before increasing to 50 mg daily. 1

Standard Adult Dosing by Indication

Major Depressive Disorder and OCD

• Start at 50 mg once daily 1
• This dose is both the starting dose and the optimal therapeutic dose for most patients, balancing efficacy and tolerability 2
• The drug can be administered at any time of day (morning or evening) 3

Panic Disorder, PTSD, and Social Anxiety Disorder

• Start at 25 mg once daily for the first week 1
• Increase to 50 mg once daily after one week 1
• This lower initial dose helps minimize activation symptoms in anxiety-prone patients 3

Premenstrual Dysphoric Disorder

• Start at 50 mg daily, either throughout the menstrual cycle or limited to the luteal phase 1

Dose Titration Strategy

• Dose adjustments should occur at intervals of no less than 1 week due to sertraline's 24-hour elimination half-life 1
• Patients not responding to 50 mg may benefit from increases up to a maximum of 200 mg/day 1
• Increase in 50 mg increments when titrating 1
• Statistically significant improvement may occur within 2 weeks, with clinically significant improvement typically by week 6, and maximal improvement by week 12 or later 3

Special Population Considerations

Elderly Patients

• No age-based dose adjustment is required 3, 4, 5
• Standard adult dosing of 50 mg daily applies unless hepatic impairment is present 3
• Sertraline is preferred in elderly patients due to lack of anticholinergic effects and minimal cytochrome P450 interactions 3, 4, 5

Patients with Alzheimer's Disease and Depression

• Start at 25-50 mg per day, with a maximum of 200 mg per day 3

Hepatic Impairment

• Reduced dose is recommended 3
• Consider starting at 25 mg and titrating more slowly 3

Renal Impairment

• No dose adjustment needed 3

Pediatric Patients (OCD)

• Children ages 6-12: Start at 25 mg once daily 1
• Adolescents ages 13-17: Start at 50 mg once daily 1
• Maximum dose 200 mg/day for both age groups 1

Critical Safety Monitoring

First Weeks of Treatment

• Monitor closely for suicidal thinking and behavior, especially in patients through age 24 years 3
• Pooled absolute rate for suicidal ideation is 1% for antidepressants versus 0.2% for placebo (Number Needed to Harm = 143) 3
• Weekly monitoring during dose adjustments is recommended 3

Common Adverse Effects

• Most adverse effects emerge within the first few weeks and include nausea, diarrhea, headache, insomnia, dizziness, sexual dysfunction, and sweating 3, 4, 5
• These effects are dose-related and typically improve with time 3

Behavioral Activation

• SSRIs can initially worsen anxiety or agitation, particularly in anxiety-prone patients 3
• Consider a subtherapeutic "test dose" approach in patients with underlying anxiety disorders 3
• If activation occurs, reduce dose back to the previous tolerated level 3

Important Drug Interactions and Contraindications

• Absolutely contraindicated with MAOIs due to risk of serotonin syndrome 3
• Exercise caution with other serotonergic agents (triptans, tramadol, fentanyl) 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, making it safer in polypharmacy situations 3, 4, 5

Administration Considerations

• Most patients can be dosed once daily 3, 1
• At very low doses (below 50 mg), some patients may require twice-daily dosing due to sertraline's shorter half-life compared to other SSRIs 3
• Can be taken with or without food 1

Common Pitfalls to Avoid

• Never increase doses at intervals less than 1 week due to the 24-hour elimination half-life 1
• Never abruptly discontinue sertraline - it is associated with discontinuation syndrome (dizziness, fatigue, myalgias, headaches, nausea, insomnia, sensory disturbances) 3
• Always taper gradually over a minimum of 2-4 weeks, or several months for long-term therapy 3
• Don't start at higher doses in anxiety disorders - the 25 mg starting dose for one week is specifically designed to minimize activation symptoms 1
• Don't assume inadequate response before allowing adequate trial duration (8 weeks at optimal dose) 3