With this post, we continue our biweekly series on medications used to treat bipolar disorder and related symptoms. We have already covered lithium, along with anti-seizure and atypical antipsychotics commonly used as anti-manic medications or mood stabilizers in bipolar disorder. We introduced our coverage of SSRI (Selective Serotonin Reuptake Inhibitor) antidepressants with a post on Prozac (fluoxetine). This week, we continue our series on SSRI antidepressants with this post on Zoloft (sertraline).

As a group, the SSRI’s share many of the same potential benefits and potential negative side effects, so we encourage you to read the Prozac post first to get up to speed about general information relating to SSRI’s, including how SSRI’s work and important cautions about using any antidepressant to treat depression in bipolar. In this post, we focus on Zoloft’s profile in treating bipolar depression and depression in general.

Potential Benefits

Zoloft’s potential benefits are in line with those of other SSRI’s. It has been approved for treatment of depression and certain anxiety conditions in patients 18 years and older:

• Major Depressive Disorder (MDD)
• Social anxiety disorder
• Panic Disorder
• Post-Traumatic Stress Disorder (PTSD)
• Premenstural Dysphoric Disorder (PMDD)
• Obsessive Compulsive Disorder (OCD) – Zoloft is also approved for OCD in children and adolescents age 6-17 years

Typical Dose

Typical doses of Zoloft range from 25 mg to 200mg taken once daily, same time each day, but follow your prescriber’s recommendations on dose and when to take it.

Potential Side Effects

Like most medications in its class, Zoloft can potentially cause any of several negative side effects. The most serious are the following:

• Increased suicidal thoughts in children or teens: Clearly there is an increased risk of suicide and suicidal thinking in people with bipolar and depression as a whole. A large review of studies done on children and adolescents who were treated with antidepressants showed that there was a slight increase in the risk that these children would develop suicidal thoughts, compared to children taking placebo. Even with the increased risk, the rate of this side effect remains very, very low. And the increased risk relates only to suicidal thinking- there have been no reports indicating any increased risk of completed suicides with the medications. These medications are far more likely to decrease the risk of suicide than to increase it. Careful monitoring and communication with the prescriber, especially early on in treatment with SSRI’s, is essential in reducing this risk as much as possible.
• Increased risk of mania: As mentioned earlier in this post, a person with bipolar disorder taking an antidepressant without the protection of a mood stabilizer may be at higher risk of shifting into mania or hypomania. While there is some indication that some antidepressants have less risk of manic switching, the risk seems to be present in all antidepressants. The rate of switching and the actual level of risk is not clear at this time – some researchers suspect it is very high and others feel it is actually much lower than is generally presumed.
• Agitation, increased anxiety, or worsening depression or other paradoxical effects: This is not the same as a true manic switch, and can occur in people with or without bipolar disorder who take SSRI’s. In a small group of people, these medicines seem to irritate the brain wiring rather than soothe it. This appears to be more common in children and adolescents, but can occur in a subset of adults as well. Close monitoring with your prescriber will be important in detecting this.
• Serotonin syndrome: When combined with medicines used to treat migraine headaches known triptans, such as sumatriptan (Imitrex), or other drugs that elevate brain levels of serotonin (including the illegal drug Ecstasy), a life-threatening condition called serotonin syndrome can occur. Symptoms include restlessness, hallucinations, loss of coordination, racing heart, increased body temperature, blood pressure fluctuations, overactive reflexes, diarrhea, nausea, vomiting, coma, and possibly death.
• Persistent pulmonary hypertension of the newborn (PPHN): There are studies showing that babies born to mothers who were taking SSRI’S in the third trimester of pregnancy have an increased likelihood of this condition. Babies born with PPHN have restricted blood flow through their heart and lungs, reducing the supply of oxygen to their bodies. This can make them very ill and increase their risk of death. If you’re pregnant or planning to become pregnant, consult with the doctor who’s managing your medications.

Other less serious side effects can include the following (Note: Many of these side effects are transient and occur when first taking these medications but do not persist.):

• Sweating
• Sleepiness
• Insomnia
• Nausea
• Diarrhea
• Tremor
• Dry mouth
• Loss of strength
• Headache
• Weight loss or gain
• Dizziness
• Restlessness
• Mania
• Changes in sexual function

Remember: Any antidepressant can take 2-3 weeks or even longer to become fully effective; it may take several weeks to work up to a therapeutic dose. This means that your depression may not lift for several weeks. I often tell patients that however they feel in the first two weeks is unlikely to be how they feel in a month – so if they are feeling some early side effects, hold on because they will likely get better. Patience is important in getting these medications to work, but if you have any concerns about how you are feeling, you should contact your doctor. You will most likely have a follow-up visit with your doctor within a month or less of starting the medications; this is a good time frame for checking in to see if benefits have started or if side effects have faded or persisted.

Zoloft has a long track record of safety and effectiveness in treating anxiety disorders in children and adults and is a powerful antidepressant in adults. It is usually one of my first choices when I am writing a new prescription for an SSRI. It is generally well tolerated and without a lot of sedation or weight gain. Some patients have reported an increased craving for carbohydrates, but just as many people do not experience this at all.

Zoloft can take a while to dose appropriately as the dosage range is large – from 25 to 200 mg per day in most cases. Since I like to start low and increase the dosing slowly, it can take a bit longer to get Zoloft to therapeutic levels than some of the other medications in this class. The upside to this, though, is that we have a much broader range of dosing options and can sometimes be more specific in matching doses to individuals. I generally use the generic form of Zoloft – sertraline – and have had no problems with this.

For more about Zoloft, visit Pfizer’s Zoloft page.

If you’ve taken any form of Zoloft for bipolar depression or are a doctor who has prescribed it, please share your experiences, insights, and observations.

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From Psych Central's website:
PsychCentral (March 6, 2009)

Symptoms Of Manic Depressive Personality (March 8, 2009)

Treatment For Bipolar Disorder (March 14, 2009)

From Psych Central's Dr. Candida Fink & Joe Kraynak:
Bipolar Disorder Medication Spotlight: Effexor (Venlafaxine) | Bipolar Beat (May 22, 2009)

    Last reviewed: 6 Mar 2009