Zoloft. What diseases does it treat?

Use sertraline (Zoloft) to treat major depressive disorder (MDD), obsessive‑compulsive disorder (OCD), panic disorder, post‑traumatic stress disorder (PTSD), social anxiety disorder (SAD), and premenstrual dysphoric disorder (PMDD). Initiate most adults at 50 mg once daily; common therapeutic range is 50–200 mg/day with a maximum of 200 mg/day. For OCD and some anxiety disorders clinicians frequently titrate toward the upper range when symptoms persist despite lower doses.

Expect clinical signal within 1–4 weeks and greater symptom reduction by 6–12 weeks. OCD may require both higher doses and longer trials compared with MDD. Adjust dose every 1–2 weeks based on symptom change and tolerability, and allow at least 6–8 weeks at a tolerable dose before declaring nonresponse for many indications.

Modify dosing for special populations: initiate older adults or patients with hepatic impairment at 25 mg/day and titrate slowly; maximum dose may be lower for significant liver dysfunction. For PMDD, use 50 mg daily either continuously or only during the luteal phase (starting about cycle day 14 through menses) depending on patient preference and prior response.

Avoid concurrent monoamine oxidase inhibitors (MAOIs); maintain a 14‑day washout between MAOI and sertraline. If switching from fluoxetine to an MAOI allow at least 5 weeks. Do not combine sertraline with linezolid or intravenous methylene blue unless under close monitoring because of serotonin toxicity risk.

Monitor adverse effects and safety: common side effects include nausea, diarrhea, insomnia or somnolence, and sexual dysfunction. Counsel patients about possible early increases in anxiety or suicidal ideation, especially under age 25, and arrange follow‑up within the first 1–2 weeks after initiation or dose change. Report signs of serotonin syndrome (agitation, hyperthermia, shivering, myoclonus) immediately.

Taper sertraline over several weeks when discontinuing to reduce withdrawal symptoms such as dizziness, paresthesia, and flu‑like complaints; adjust taper speed to symptom severity and prior treatment duration. For drug interactions, review the full medication list for triptans, certain antibiotics, and herbal products such as St. John’s wort, and consult a pharmacist when combining agents.

Major Depressive Disorder: dosing schedules, expected timeline for response, and when to change therapy

Initiate sertraline 50 mg once daily for most adults; reduce to 25 mg once daily for frail elderly patients, those with significant hepatic impairment, or patients who exhibit marked anxiety or agitation at baseline.

Dosing and administration

Typical adult range: 50–200 mg once daily. Increase by 50 mg increments at intervals of 1–2 weeks based on tolerability and clinical response, with a usual target of 100 mg by week 2–4 when needed. Maximum recommended dose: 200 mg/day. Take with or without food; dose in the morning if activation/insomnia occurs, consider evening dosing if sedation predominates. No routine renal dose adjustment; reduce starting dose and titrate slowly for moderate–severe hepatic impairment. For adolescents (12–17 years): start 25 mg once daily for several days, then 50 mg once daily; upper adolescent dosing often mirrors adult dosing but follow pediatric approvals and specialist guidance. For children under 12 refer to pediatric prescribing information before adjusting dose.

Expected timeline for response and criteria to change therapy

Early changes in sleep, appetite, or energy may appear within 1–2 weeks; meaningful improvement in depressed mood and anhedonia commonly appears by 4–6 weeks. Assess response with standardized scales (PHQ-9, HAM-D): remission commonly defined as PHQ-9 <5; response defined as ≥50% reduction in baseline score.

At 2–4 weeks: verify adherence, confirm adequate dosing, and manage side effects. If there is minimal change and tolerability is acceptable, escalate dose toward 100 mg by week 2–4. At 6–8 weeks on a therapeutic dose (usually ≥100–150 mg unless limited by side effects):

- If ≥50% improvement: continue current dose for at least 4–6 months after remission before considering tapering for first episode.

- If 25–49% improvement (partial response): consider optimization strategies – increase dose toward 200 mg if tolerated, add evidence-based augmentation (e.g., bupropion, low-dose atypical antipsychotic such as aripiprazole per local labeling, or lithium), or combine with structured psychotherapy. Select augmentation based on symptom profile, comorbidities, and drug interactions.

- If <25% improvement (nonresponse) after 6–8 weeks at an adequate dose: switch treatment. Options include switching to another SSRI, an SNRI, bupropion, or mirtazapine, or referral for specialist care. When planning a switch to or from an MAOI allow a 14-day washout after sertraline discontinuation; avoid combining sertraline with MAOIs. When switching across serotonergic agents, monitor for serotonin syndrome and manage titrations per prescribing guidance.

Monitor suicidality closely during the first weeks and after dose changes, especially in patients under 25. Reassess comorbid conditions, substance use, psychosocial stressors, and adherence before labeling a trial inadequate. If safety or complex treatment resistance emerges, refer to psychiatry for consideration of combination strategies, transcranial magnetic stimulation, or electroconvulsive therapy.

Panic Disorder and Panic Attacks: initial titration, preventing escalation, and acute management strategies

Begin sertraline at 25 mg once daily for 3–7 days to reduce activation, increase to 50 mg daily, then titrate by 25–50 mg every 1–2 weeks as tolerated; target dosing commonly centers around 100 mg/day with an effective range of 50–200 mg/day and a maximum of 200 mg/day.

Initial titration protocol

Use a conservative upward schedule for patients with frequent panic attacks, prominent autonomic arousal, or sensitivity to medication activation: 25 mg x 3–7 days → 50 mg x 7–14 days → increase by 25–50 mg every 7–14 days to desired response. If new or worsened panic appears during early weeks, pause escalation and maintain the last tolerated dose for 1–2 additional weeks before trying a slower increase.

Elderly patients and those on interacting medications (strong CYP2D6 or CYP3A4 inhibitors) should start at 25 mg and extend each titration interval to 2–4 weeks. If activation (restlessness, insomnia, increased panic) emerges, consider shifting dosing time (morning versus evening based on symptom direction), dose reduction to prior tolerated level, or adding a brief adjunctive anxiolytic while reassessing.

Parameter	Recommendation
Starting dose	25 mg once daily for 3–7 days
Standard start	50 mg once daily after initial 3–7 days
Titration increment	25–50 mg every 1–2 weeks as tolerated
Typical target	100 mg/day (range 50–200 mg/day)
Maximum	200 mg/day
Early exacerbation management	Hold dose, slow titration, short-term benzodiazepine, reassess within 1–2 weeks

Preventing escalation and acute management strategies

For escalating panic frequency or intensity during initiation, implement a stepped plan: 1) stabilize sertraline at the last tolerated dose, 2) offer short-term benzodiazepine for severe acute symptoms, 3) schedule prompt clinical follow-up within 3–7 days, and 4) assess for comorbid conditions, substance use, or medication interactions that amplify panic.

Practical acute self-management steps to reduce attack severity: sit upright, practice diaphragmatic breathing (inhale 4 seconds, hold 4 seconds, exhale 8 seconds) for several cycles, use a 5-4-3-2-1 grounding exercise to refocus attention, and apply progressive muscle relaxation when able. These techniques lower sympathetic surge and can be combined with medication when needed.

Pharmacologic acute options (use lowest effective dose briefly): alprazolam 0.25–0.5 mg orally PRN (repeat per clinician guidance) or clonazepam 0.25–0.5 mg orally PRN; in emergency settings, lorazepam 1–2 mg IV/IM may arrest severe panic with marked autonomic destabilization. Limit benzodiazepine exposure to the shortest period necessary (commonly 1–4 weeks) and plan tapering to avoid dependence; arrange definitive treatment (SSRI optimization and/or structured behavioral therapy) concurrently.

For patients with pronounced sympathetic symptoms during discrete triggers, a short course of a beta-blocker such as propranolol 10–40 mg orally before a known trigger can reduce palpitations and tremor; avoid for patients with asthma or certain cardiac conduction issues. Refer promptly to psychiatry if panic escalates despite conservative measures, if suicidal ideation emerges, or if functional impairment persists despite optimized pharmacologic and behavioral efforts.

Obsessive-Compulsive Disorder (OCD): target dose ranges, duration of therapy, and adjunctive treatment options

Use sertraline at 100–200 mg/day for OCD: start 50 mg once daily, increase by 50 mg every 1–2 weeks as tolerated, with a common target of 200 mg/day for full symptom control.

Consider an adequate pharmacologic trial to be at least 12 weeks at a therapeutic dose (typically ≥200 mg for sertraline). Assess clinical change at 8–12 weeks; if partial benefit appears, continue to 12 weeks at target dose before declaring nonresponse.

Maintain treatment for 12–24 months after remission for a first episode. For severe, chronic, or recurrent OCD, recommend extended maintenance and discuss long-term therapy; multiple relapses justify ongoing treatment beyond 2 years and possibly indefinite maintenance under specialist supervision.

Offer cognitive-behavioral therapy with exposure and response prevention (ERP) alongside medication for most patients. Typical ERP regimens run 1–2 sessions weekly for 8–20 sessions; combine SSRI + ERP when baseline severity is high or when medication yields only partial symptom reduction.

If response is inadequate after 8–12 weeks at an adequate SSRI dose, consider augmentation before switching. Antipsychotic augmentation has the strongest evidence for SSRI-resistant OCD: risperidone 0.5–3 mg/day (low doses such as 0.5–1 mg/day often help) or aripiprazole 5–15 mg/day. Expect augmented benefit within 4–8 weeks; monitor for extrapyramidal symptoms, metabolic changes, and elevated prolactin with risperidone.

Use clomipramine (150–250 mg/day) as an alternative or second-line option when two SSRIs plus augmentation fail or are contraindicated. Start low and titrate; check baseline ECG in patients with cardiac risk, monitor anticholinergic effects, and avoid concurrent high-dose SSRI combinations because of serotonin syndrome risk–allow appropriate washout intervals when switching between serotonergic agents (standard 14-day washout before MAOI use).

Consider neuromodulation for treatment-refractory cases: deep TMS targeting medial prefrontal cortex/ACC typically delivered as ~20 sessions over 4 weeks; deep brain stimulation (DBS) of ventral capsule/ventral striatum is reserved for severe, chronic OCD after failure of multiple SSRIs, clomipramine, adequate CBT/ERP, and at least one augmentation trial–refer to a specialized center for DBS evaluation.

Choose switching versus augmentation based on early trajectory: for partial responders, try augmentation; for true nonresponders after 12 weeks at target dose, switch to clomipramine or another SSRI/venlafaxine, or refer for specialized care. Document baseline severity, prior treatments, and functional impairment before major changes.

Monitor routinely for SSRI adverse effects (GI symptoms, sexual dysfunction, activation, hyponatremia in older adults) and for antipsychotic/clomipramine risks (metabolic profile, EPS, QT prolongation risk, anticholinergic burden). Taper gradually when stopping to reduce discontinuation symptoms and coordinate care with psychotherapy and specialty services for complex cases.

Social Anxiety Disorder: practical dosing for generalized vs performance anxiety and managing anticipatory symptoms

For generalized social anxiety disorder, start sertraline 50 mg once daily; if patients are sensitive to side effects begin at 25 mg daily and increase by 25–50 mg every 1–2 weeks as tolerated. Aim for a target range of 100–150 mg/day for most responders, with a therapeutic range of 50–200 mg/day. Maintain each titration step for at least 7–14 days unless adverse effects mandate a slower approach.

When anxiety occurs only in performance or situational settings, rely on situational agents rather than sertraline for acute relief. Propranolol 10–40 mg orally 60–90 minutes before the event reduces tremor and autonomic symptoms; lorazepam 0.5–1 mg or clonazepam 0.25–0.5 mg taken 30–60 minutes before a performance provides short-term anxiolysis but reserve benzodiazepines for infrequent use because of tolerance and dependence risks. If performances are frequent (weekly or more), use daily sertraline (25–50 mg start, titrate to target as above) because SSRIs require weeks to take effect.

Address anticipatory anxiety with a combined pharmacologic and behavioral plan. For acute pre-event spikes, prescribe a single-dose beta-blocker or short-acting benzodiazepine as above for a limited number of events (recommendations: no more than 2–4 consecutive days without review). For patients already on sertraline who report heightened pre-event activation during the first 1–2 weeks, temporarily add propranolol for autonomic symptoms or use low-dose benzodiazepine for the first 1–2 weeks only, then taper off as SSRI benefit emerges.

Adjust sertraline timing and titration to limit anticipatory activation. Move dosing to morning if patients experience initial activation or insomnia; move to evening if sedation predominates. For marked sensitivity, use 25 mg increments every 10–14 days. If GI upset occurs, take medication with food and consider an initial lower start (25 mg) with slower increases.

Behavioral measures shorten the window of anticipatory distress and work well alongside medication. Teach diaphragmatic breathing (5–6 breaths/min for 5 minutes pre-event), brief in-situ exposure exercises performed 2–3 times weekly, and one-session rehearsal of the opening 3–5 minutes of a performance to reduce peak anxiety. Combine these with a written plan for pre-event routines (sleep, caffeine avoidance, light meal) to blunt physiological triggers.

Evaluate response at defined milestones. Expect initial change in social avoidance or anxiety symptoms within 4–6 weeks; assess clinical improvement by 8–12 weeks at a therapeutic dose. If partial response at 8 weeks on ≥100 mg/day, consider further upward titration toward 150–200 mg/day or add a targeted adjunct (beta-blocker for autonomic symptoms or brief CBT focused on exposure). If no meaningful improvement after 12 weeks at an adequate dose, discuss alternative SSRI/SNRI or referral for specialized CBT.

Screen for contraindications and interactions before combining agents: avoid beta-blockers in patients with uncontrolled asthma or marked bradycardia; use benzodiazepines cautiously with history of substance use disorder; check for interacting CYP inhibitors that raise sertraline levels. Document plans for short-term adjunctive use and arrange close follow-up during the first 4–8 weeks to adjust dose and manage side effects.

Use in Adolescents and Adults: age-specific dosing, safety monitoring, and addressing emergence of suicidal thoughts

Begin sertraline with age-appropriate starting doses: adults usually 50 mg once daily; adolescents start lower (25–50 mg) and titrate more slowly with proactive safety checks.

• Age-specific dosing
  • Children 6–12 years (OCD only, FDA-approved): start 25 mg once daily for 1 week, increase to 50 mg daily, then raise by 25–50 mg every 1–2 weeks as tolerated; target often 50–200 mg/day (max 200 mg).
  • Adolescents 13–17 years: commonly start 25–50 mg daily depending on severity and prior SSRI exposure; increase every 1–2 weeks to an effective dose, typical range 50–200 mg/day. For OCD, aim for higher end (100–200 mg) if needed and tolerated.
  • Adults (18+): start 50 mg once daily; increase by 25–50 mg at intervals of 1–2 weeks for partial/no response; usual therapeutic range 50–200 mg/day. Use the lower end for anxiety-predominant presentations and titrate up for incomplete response.
  • Hepatic impairment: reduce initial dose (e.g., 25–50 mg) and increase more slowly; avoid rapid titration or high maintenance doses in moderate–severe hepatic disease.
  • Renal impairment: no routine adjustment required for mild–moderate disease; use clinical judgment for severe cases.

• Baseline safety evaluation
  • Assess suicide risk, prior self-harm history, family history of bipolar disorder, substance use, and current medications (anticoagulants, NSAIDs, MAOIs, other serotonergic agents).
  • Perform pregnancy test for females of reproductive potential and review plans for conception or breastfeeding.
  • Obtain basic labs if indicated: sodium (elderly or diuretic use), liver function tests (suspected hepatic disease), and INR if on warfarin or other anticoagulants.
  • Consider baseline ECG when the patient has cardiac disease, is on other QT-prolonging drugs, or electrolyte abnormalities.
  • Document weight and growth percentiles in adolescents and monitor periodically.

• Monitoring schedule and targets
  • Contact within 3–7 days after initiation or any upward dose change to assess tolerability (nausea, insomnia, activation, akathisia).
  • Clinic visit at 2–4 weeks to evaluate response and adverse effects; earlier visits for adolescents or high-risk patients (weekly or biweekly first month).
  • Evaluate symptom change at 6–8 weeks for adequacy of dose; if partial response, continue titration or consider augmentation/switch guided by diagnosis and prior response.
  • After stabilization, follow-up every 1–3 months for the first 6 months, then every 3–6 months while continuing therapy; reassess growth in adolescents at each visit.
  • Use validated tools (PHQ-9/PHQ-A, GAD-7, CY-BOCS for OCD, C-SSRS for suicidal ideation) to quantify symptoms and track trends.

• Recognizing and managing emergent suicidal thoughts
  • Be aware that randomized-trial meta-analyses found a small absolute increase in suicidal ideation/behavior in children and adolescents (approximately 4% on SSRIs vs 2% on placebo); risk is greatest during the first month and after dose changes.
  • At every early contact ask directly about suicidal thoughts, plans, intent, and access to means; use the C-SSRS or similar structured tool for clarity and documentation.
  • If the patient has imminent intent or a concrete plan or access to lethal means:
    1. Arrange immediate emergency evaluation or hospital admission.
    2. Remove or limit access to firearms, medications, and other means; involve caregivers and document the safety plan.
  • If suicidal ideation is present without imminent intent:
    1. Increase monitoring frequency (daily calls or contacts for several days, in-person within 24–72 hours).
    2. Involve family/caregivers in supervision and means restriction with patient consent when safe and appropriate.
    3. Evaluate for akathisia or severe activation (restlessness, pacing, agitation); treat akathisia (dose reduction, propranolol, or switch agent) rather than assuming medication is ineffective.
    4. Consider urgent psychiatry referral for reassessment of diagnosis (screen for bipolar disorder) and treatment plan; consider short-term adjunctive anxiolytic or sleep agent if severe insomnia or agitation is driving risk.
    5. Document risk assessment, safety plan, notification of caregivers, and rationale for medication changes or continued treatment.
  • Do not stop sertraline abruptly without a plan; if discontinuation is required because of severe adverse effects or emergent mania, provide bridging care and arrange timely psychiatry follow-up.

• Drug interactions and practical precautions
  • Avoid MAOI coadministration; allow a 14-day washout after stopping an MAOI before starting sertraline. When switching from fluoxetine, allow approximately 5 weeks before starting an MAOI.
  • Monitor INR when starting or stopping sertraline in patients on warfarin; watch for increased bleeding risk with NSAIDs, antiplatelet agents, or anticoagulants.
  • Watch for serotonin syndrome when combining sertraline with other serotonergic drugs (triptans, SNRIs, linezolid, tramadol); educate patients about high fever, confusion, myoclonus, and autonomic instability signs.
  • Adjust dose or choose alternatives when strong CYP inhibitors are co-prescribed; consider consultation with pharmacy for complex polypharmacy cases.

• Quick clinical checklist for prescribers
  • Confirm indication and age-appropriate starting dose.
  • Baseline suicide and bipolar screening; pregnancy test if applicable.
  • Plan contact within 3–7 days, formal visit at 2–4 weeks, weekly check-ins for adolescents first month.
  • Use structured suicide-assessment tool at each early contact.
  • Document safety plan, involve caregivers when appropriate, and arrange psychiatry referral for any emergent suicidal ideation or poor tolerability.