What should be done if a patient with a history of depression or anxiety, who has been taking Zoloft (sertraline) 50mg, has not been off the medication for about a year?

Restarting Zoloft After One-Year Discontinuation

If a patient has been off Zoloft (sertraline) 50mg for approximately one year, restart at the standard initial dose of 50mg once daily, as prior response to sertraline is the strongest predictor of future response and there is no need for dose adjustment based solely on the duration of discontinuation. 1, 2

Rationale for Restarting at Standard Dose

• The FDA-approved starting dose for sertraline in depression and anxiety disorders is 50mg once daily, which should be used regardless of previous treatment history 2
• Prior response to sertraline makes it the ideal medication to restart, as patients who previously responded well are likely to respond again 1
• After one year off medication, the patient's system has fully cleared sertraline (elimination half-life is 24 hours), so no tapering or gradual reintroduction is necessary 2, 3

Treatment Duration to Prevent Future Relapse

• Continue sertraline for a minimum of 4-9 months after satisfactory response for recurrent depression, and strongly consider longer duration of ≥1 year or indefinite maintenance therapy given this patient's history of discontinuation and recurrence 1, 4
• Discontinuation of effective antidepressant treatment commonly leads to relapse—studies show 26-52% of patients relapse when sertraline is discontinued, compared to only 5-16% who continue medication 1
• After a first episode, recurrence probability is 50%; after two episodes it increases to 70%; after three episodes it reaches 90% 1

Dosing Algorithm

• Start with 50mg once daily (morning or evening, patient preference) 2, 3
• Assess response at 4 weeks and 8 weeks using standardized symptom measures 4
• If inadequate response after 4-6 weeks at 50mg, increase to 100mg daily 2
• Maximum dose is 200mg daily, with dose increases in 50mg increments at intervals of no less than 1 week 2, 3
• The optimal therapeutic dose for most patients is 50mg daily, which balances efficacy and tolerability 3

Critical Monitoring Requirements

• Monitor closely for suicidal ideation during the first 1-2 months after restarting, as SSRIs carry FDA black box warnings for treatment-emergent suicidal thinking, particularly in patients under age 24 1, 4
• Assess for common initial side effects (nausea, diarrhea, insomnia, headache) which typically resolve within 2-4 weeks 5, 6
• Confirm medication adherence at each follow-up visit 4

Why Sertraline Remains First-Line

• Sertraline has proven efficacy across depression and anxiety disorders with an optimal balance of effectiveness, safety, and tolerability 1, 5, 7
• Low lethality in overdose compared to tricyclic antidepressants 5
• Minimal drug-drug interactions due to weak inhibition of cytochrome P450 enzymes 5, 6
• No dose adjustment needed based on age alone 6, 3
• Well-tolerated in patients with medical comorbidities 7, 6

Common Pitfall to Avoid

• Do not start at a lower "test dose" of 25mg unless the patient has panic disorder, PTSD, or social anxiety disorder, as the FDA-approved starting dose for depression is 50mg daily 2
• Do not discontinue prematurely before allowing 6-8 weeks for full therapeutic effect 4
• Do not make dose changes more frequently than weekly intervals due to sertraline's 24-hour elimination half-life 2, 3