Sertraline (Zoloft)

What sertraline is

Sertraline is a medication sold under the brand name Zoloft. It works mainly on serotonin, one of the chemical messengers nerve cells use to communicate, and medicines that work this way are often called SSRIs (selective serotonin reuptake inhibitors). It is widely used and well studied.

What it treats

Your clinician might suggest sertraline for one of these, among other possible off-label uses:

• Depression
• Anxiety, including panic and social anxiety
• Obsessive-compulsive disorder
• Post-traumatic stress disorder
• Premenstrual dysphoric disorder (PMDD)

Whether it is a good fit depends on several factors, including your history and what you are working on. As with everything in psychiatry, that is decided case by case.

Who should not take sertraline. FDA labeling lists a few firm exclusions. Sertraline is not taken together with, or within 14 days of, a group of medicines called MAOIs, because the combination can cause a dangerous reaction called serotonin syndrome; that group includes the antibiotic linezolid and methylene blue given into a vein. It is not taken with pimozide. It is not for anyone who has had a serious allergic reaction to sertraline. The liquid form contains alcohol, so it is not taken with disulfiram. Make sure your clinician has your full medication list, including anything started recently or stopped within the last two weeks.

How it works

Honestly, no one knows with complete certainty how sertraline produces its benefit. What research suggests is that it helps keep more serotonin available in the spaces between nerve cells, and that this serotonin effect is central to how it helps. The biology is only part of the picture: how much a medication helps, and how it feels, is individual. Two people on the same medication can have very different experiences.

How to take it

There is no single right way to take sertraline; it depends on you and your clinician. Some people start low and increase slowly, others do not, and the timing and the form (tablet or liquid) vary. The plan you and your clinician make together is the one to follow, not a number you read online. A few general points apply broadly:

• Take it the way you and your clinician agreed. Taking it with food can help if it bothers your stomach.
• If you miss a dose, ask your clinician or pharmacist what to do rather than doubling up.
• Try not to stop on your own. Stopping suddenly can cause uncomfortable effects, and your clinician can taper it gently if and when that makes sense.

What to expect

This varies from person to person. Some effects can show up before the benefit does: possible side effects, if they happen, often appear in the first days, while any lift in mood or easing of anxiety usually takes longer, commonly a few weeks and sometimes more. That early stretch is common and tends to ease. If nothing has shifted after a fair trial, that is useful information, not a dead end, and there are other options. As always, this is case by case.

Side effects

Not everyone gets side effects, and many that do happen ease over the first weeks. The lists below are possibilities, not certainties.

Possible more common side effects:

• Nausea, loose stools, or heartburn, especially early on
• Trouble sleeping, or feeling drowsy or tired
• Headache, dizziness, or a fine tremor
• Sweating more than usual
• Changes in sex drive or sexual function
• Feeling restless or keyed up, especially early on

If any of these stick around or bother you, they are worth raising. Send a non-urgent message through the patient portal or bring it up at your next visit; often a small change helps. Restlessness or anxiety that is new, worsening, or severe is a reason to contact your clinician promptly rather than wait.

Less common, but concerning side effects that could require emergency care:

• Signs of an allergic reaction. Call 911 right away for swelling of the face, lips, tongue, or throat, or trouble breathing. Contact your clinician promptly about a new rash or hives.
• Serotonin syndrome: agitation, confusion, a racing heart, fever, heavy sweating, or stiff or twitching muscles, sometimes after another medication is added
• Unusual bleeding or bruising
• A seizure
• Feeling abnormally high, wired, or irritable, with racing thoughts and far less need for sleep than usual
• Eye pain or redness, or changes in vision such as blurred sight or seeing rings around lights
• Headache with weakness, confusion, trouble concentrating or remembering, or feeling unsteady
• Any new or worsening thoughts of harming yourself, whether or not you think the medication is behind it

For any of these, use the help options at the top of this page: call 911 or go to the nearest emergency department for a medical emergency or severe reaction, or call or text 988 for a mental health crisis.

If serotonin syndrome or a seizure is the concern, tell the clinicians treating you everything you take, including this medication. They may decide to stop it.

Pregnancy and breastfeeding

If you are pregnant, thinking about it, or breastfeeding, this is worth going through together rather than settling from a page. What follows is what the research currently shows. Tell your clinician before changing anything, and do not stop suddenly on your own.

In pregnancy

Sertraline is among the most studied medications of its kind in pregnancy, with more than 25,000 exposed pregnancies reported. Most studies have not found a higher chance of birth defects. Some have suggested one, including heart defects, but studies that look only at pregnancies in people who have depression find similar rates whether sertraline was taken during pregnancy or stopped before it. Studies of miscarriage are limited and have not shown an increase. For scale, about 3 in 100 babies are born with a birth defect, before any particular exposure is considered.

A few other findings come up often enough to name:

• Preterm birth and low birth weight. Some studies suggest a higher chance. Depression and anxiety are themselves associated with these outcomes, which makes the two hard to separate.
• A newborn lung condition. Some studies suggest that SSRIs taken in the second half of pregnancy might raise the chance of persistent pulmonary hypertension of the newborn, and others have not found this. It occurs in about 1 or 2 of every 1,000 births to begin with, and if SSRIs do raise it, the overall chance stays under 1 in 100.
• Bleeding after delivery. FDA labeling notes that SSRI use, particularly in the month before delivery, has been associated with a higher chance of postpartum hemorrhage. Worth making sure whoever delivers your baby knows what you are taking, well before the day.
• Later learning and behavior. Most large studies have not found differences. Where they have appeared, the comparison was against children of parents without depression; studies restricted to children whose parents had depression mostly do not find them.

Symptoms in the newborn. Babies exposed late in pregnancy can have temporary symptoms in the first days, and in most cases these are mild and resolve on their own within a couple of weeks. They can include irritability, jitteriness, trembling, more crying than usual, changes in sleep, floppy muscle tone, a bluish tinge to the skin, trouble feeding, trouble holding a steady temperature, and pauses in breathing. Not every exposed baby has them, and some babies stay in the nursery or NICU until they pass. FDA labeling adds that some newborns have needed a longer hospital stay, help with breathing, or tube feeding. The useful thing you can do is make sure the delivery team knows about the medication ahead of time, so someone is watching for it.

While breastfeeding

Sertraline passes into breast milk in small amounts and is usually not detectable in the baby's blood. LactMed, the National Institutes of Health lactation database, notes that most authoritative reviewers consider sertraline a preferred antidepressant during breastfeeding. Infants followed to 5 years of age have not shown effects on development, and most breastfed babies have no side effects at all. If yours seems unusually irritable or sleepy, call the pediatrician.

One exception is worth flagging: rarely, a baby born early who clears medication slowly can build it up, so tell your clinician if your baby was preterm.

Separately, some people taking an SSRI have a harder time getting breastfeeding established, and it is not clear how much of that is the medication and how much is the condition being treated. It is a good reason to line up lactation support early rather than to assume it will not work.

If you are a man taking sertraline

SSRIs can cause sexual side effects that may affect fertility. A father's use of sertraline is not expected to raise the chance of birth defects.

Registries

There is a national registry that follows pregnancy outcomes for people taking psychiatric medications, and you can enroll yourself rather than waiting to be asked. It is listed in the references at the bottom of this page.

When to reach out, and where

For routine questions, side effects that can wait, or how things are going, send your clinician a message through the patient portal. These are part of your ongoing care and are answered in the normal course of a few business days, so they are best for things that are not urgent.

If something feels urgent, you do not need to wait for a reply. The help options at the top of this page are the fastest way to get care: 911 or the nearest emergency department for a medical emergency or severe reaction, or 988 any time for a mental health crisis or thoughts of self-harm.

Questions to ask your clinician

• What are you hoping sertraline will help with in my case?
• How and when will we know if it is working?
• What should I do if I notice side effects?
• How long should I give it before we reassess?
• If pregnancy is possible for me, or I am breastfeeding, what should we talk through?
• What is the plan if this one turns out not to be the right fit?
• How will we handle stopping it, if and when we get there?