Crazy Meds’ Comprehensive Pages on Zoloft (sertraline hydrochloride) (1 of 2)

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This is essentially everything we know about Zoloft (sertraline hydrochloride) on two big-ass pages. On this page is brand / trade names to odds of working and comparisons with other meds, or pretty much everything most people want to know. Page two is pharmacokinetics to the bibliography, or: I’m sure somebody wants to read it.

The titles for most sections link to the pages for those sections. While all the information is on these two comprehensive pages, the individual section pages go into a little more detail about what it all means.

1.  Names, Availability, Brand vs. Generic Issues, Forms

1.1  US brand name: Zoloft

Just because a drug is available in one country doesn’t mean you can get it everywhere. Even if a medication is available elsewhere, it won’t necessarily have the same brand, or trade name everywhere it is sold.

1.2  Available as Zoloft in these countries¹

Argentina, Brazil, Bulgaria, Canada, China, Czech Republic, Denmark, Finland, France, Germany, Hong Kong, Hungary, Indonesia, Italy, Korea, Malaysia, Netherlands, Peru, Philippines, Poland, Sweden, Switzerland, Taiwan, Thailand, Uruguay, Venezuela

1.3  Other trade name(s) for Zoloft used in these countries¹

• Altruline: Mexico
• Aremis: Spain
• Atruline: Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, Panama
• Besitran: Spain
• Deprax: Chile
• Dominum: Colombia, Peru
• Doxime: Paraguay
• Gladem: Austria, Germany
• Lesefer: Colombia
• Lustral: England, Ireland, Israel
• Sosser: Colombia
• Zolof: Colombia
• Zosert: India

1.4  Generic Name and Availability

A drug’s generic, or international nonproprietary name (INN) is how it is uniquely identified around the world⁴. The generic version of a med is are often available in other countries long before they are in the US.

1.5  sertraline hydrochloride is available in these countries²

Belgium, Colombia, Brazil, Indonesia, Korea, Malaysia, Thailand

1.6  Branded generic names³

• Fatral: Indonesia
• Fridep: Indonesia
• Nudep: Indonesia
• Seltra: Korea
• Sercerin: Brazil
• Serlain: Belgium
• Serlift: Malaysia
• Sertranex: Colombia
• Sertranquil: Colombia
• Traline: Korea

1.7  Specific generics with complaints, or preferred generics manufacturers

In theory the generic version of a med is the same as the brand-name version. In practice that is usually, but not always the case. Especially with crazy meds. If we know of any problems with particular generics, or if some generics are better than others, we’ll let you know.

1.8  Generics with independently-tested bioequivalence

1.9  Forms and Classes

Available/supplied as:
25, 50 and 100 mg tablets.
20mg/mL oral concentrate.
OK, Pfizer keeps telling us that there’s not much evidence that Zoloft works any better at dosages above 50mg a day, so the 100mg tablets must be so you can split them in half and save money, right? And if the recommended dosage for everything is 50mg a day, why is the oral concentrate the equivalent of a non-existent 20mg tablet?

2.  Approved and Off-Label Uses

Drugs are officially approved to be used for certain things, and they may be approved for one thing in one country but something else entirely in another.⁵

2.1  US FDA approved use(s)

• Major Depressive Disorder (MDD) approved 30 December 1991
• Obsessive-Compulsive Disorder (OCD) in both adults (approved 28 October 1996) and children (approved October 1997)
• Panic Disorder (July 1997)
• Post Traumatic Stress Disorder (PTSD). Zoloft was approved for short-term (acute) use on 7 December 1999 (fitting date), and for chronic (long-term) use on 16 August 2001 (just in time!).
• Premenstrual Dysphoric Disorder (PMDD) (approved 20 May 2002)
• Social Anxiety Disorder (approved 10 February 2003)

2.2  Zoloft is approved elsewhere for

2.3  Common off-label uses

Meds are often prescribed for conditions or people they aren’t approved to treat. This is known as off-label prescribing. Some off-label prescribing is so common that lots of people think the medication is a first-line treatment for the condition it’s prescribed to treat.

• Generalized Anxiety Disorder (GAD), although the numbers aren’t all that great in that study or this one. Which probably explains why Zoloft was never approved for GAD.
• Major Depression in people with various chronic heart problems, including
  • acute myocardial infarction or unstable angina
  • Acute Coronary Syndrome
  • Depression and panic after a heart transplant
  • In spite of the clever acronym (SADHART: Sertraline AntiDepressant Heart Attack Randomized Trial) and having one of the lowest rates of cardiovascular side effects of all antidepressants?, Zoloft didn’t really help all that much.
• Eating Disorders, including
  • binge eating
  • bulimia
  • anorexia nervosa - although the way the abstract reads the success seems due to Zoloft’s effect on depression and OCD, and the anorexia was an expression of those conditions
  • sleep eating - while not necessarily as effective as Topamax, the side effects suck a lot less.
• Menopause symptoms, especially hot flashes. Sometimes it works. Sometimes it doesn’t, or makes it worse. Basically it’s an equal chance that Zoloft will make it better, worse, or do nothing. And if it does do anything, it’s just as likely to be a big change or a small change.

2.4  Less common/experimental off-label uses

When all else fails and you’ve run out of other options, the experimental use of some drug may be your best chance at treating something. Be careful! Otherwise safe meds can be downright dangerous when used for some things.

• Post-stroke emotional incontinence. Don’t they make adult diapers for that sort of stuff? Also known as pseudobulbar affect (PBA), pathological laughing and crying, and emotional lability - the last one is now mostly used for a medication side effect with a slightly different meaning - PBA is similar to ultradian rapid cycling in bipolar disorder. One minute everything is so fantastic that you can’t help but laugh at a bird pooping on the grass. Five minutes later you’re plunged into despair and crying because there’s a bird turd on your lawn. Keep repeating every five minutes for hours and hours, day after day. Zoloft also helped this guy, even though his doctor called it ballism.
• Smoking cessation. It’s not all that great by itself. The data are all over the map when Zoloft is used in combination with other meds.

2.5  Failed off-label uses

Irritable Bowel Syndrome (IBS). Unlike other SSRIs, Zoloft is consistently more likely to give you the runs than constipation.

2.6  Potentially dangerous off-label uses

2.7  When / why you should take Zoloft

Just because a medication is approved or commonly prescribed for a particular condition doesn’t necessarily mean you should be taking it for that condition. There could be a drug that might be better to try first, or at least talk to your doctor about trying first, or the condition you have isn’t bad enough to warrant medication at all.

• You have depression that involves lots of sleeping, lots of eating, and lots of never leaving your room.
• Another SSRI almost worked for depression with the above features.

2.8  When / why you should not take Zoloft

• You or your doctor suspect you might be bipolar. Unless you really, really want to find out for sure.
• You’re frequently agitated.
• Your depression features insomnia and not eating.

3.  Chances of Working & Comparisons with Other Meds

Two of the most important things to know when deciding on which med is the best for a particular condition⁶: how likely is it to work and how long will it take.
The odds of a med working for a particular condition and how long it generally takes to work should be fairly easy to nail down, and not need to be summed up by the Internet shorthand YMMV (Your Mileage May Vary). Unfortunately because no one is quite sure exactly what causes various conditions - further complicated when everything is a spectrum disorder - and they’re never really sure about how a med works in the first place, especially when there are lots of contradictory and/or questionable studies,⁷ we can only give you an idea somewhat less vague than support groups and PI sheets, but certainly more accurate than the implied “it fixes everything all the time!” promises of pharmaceutical advertising.
See our page on the tests researchers use to measure the efficacy of medications, including during clinical trials to get FDA approval.

3.1  How long until Zoloft starts working:

Like all SSRIs: anywhere from a couple days to over a month, although you’ll probably feel more awake and energetic, or at least start sleeping a little better, in two to four days. If you don’t feel any positive benefit after four weeks for depression alone, or two weeks for anxiety or depression and anxiety, then you should talk to your doctor about either another SSRI or, if you already tried another SSRI or an SNRI before and it didn’t work, trying a med that hits another neurotransmitter.

3.2  Likelihood Zoloft will work for its approved indications:

Like all SSRIs Zoloft has about a 40–50% chance of working, factoring in having to stop taking it for intolerable side effects. Those are actually decent odds for serious brain cooties like chronic, severe depression and social anxiety bad enough to keep you from holding a job.

Zoloft is better for conditions in the anxiety spectrum than those in the depression spectrum. Which is funny given how agitated and nervous it makes a lot of people feel. It’s not just any anxiety Zoloft is good for, but social anxiety/phobia, which really is different from other forms. So they aren’t lying to you all that much with those cheesy ads featuring the sad and lonely blob.

Zoloft works well for chronic depression (i.e. every day for months on end). Like Wellbutrin, Zoloft is especially good for depression defined by sleeping too much, eating too much, and withdrawing from the world. Zoloft is more likely to work for you if you have anxiety combined with depression, although Celexa is somewhat more likely to work for anxious-depression (defined as being severely anxious and severely depressed, either simultaneously or at different times).

3.3  For off-label applications:

Premature ejaculation - pretty good. Going from under a minute to around 10 minutes with less risk of not being able to do anything at all as there is with Paxil and Prozac are decent results.

3.4  Zoloft versus other Antidepressants for approved treatments:

Based upon the studies, the source material, and anecdotal evidence.

For all approved applications:

• Celexa vs. Paxil vs. Zoloft - which is better for medication compliance? Getting people to stay on their meds is essential in getting them to work. That seems obvious, but all the clinical trials in the world don’t mean shit if someone won’t get a refill. This study looks at just that, which med gets the most first refills for approved treatments: depression, social anxiety, and PTSD. The winner: it’s a statistical tie between Zoloft and Celexa, with 54.70% and 54.49% of people taking them getting refills. Given the size of the study - over 14,000 people - Paxil’s first refill rate of 50.99% is significantly poorer, but isn’t overwhelmingly so.
• Celexa vs. Paxil vs. Zoloft - which med do people stay on longer? This is an indicator of which one generally sucks the most, not which is the most successful, as this is for people who still needed treatment. 14,933 people with depression, PTSD, or social anxiety disorder all taking brand and not generics. The results: Paxil sucks the most, Celexa sucks the least.

For depression spectrum disorders:

• Zoloft vs. SNRIs (mostly Effexor) and other SSRIs. Celexa and Effexor are better for depression, including depression with anxiety, than Zoloft. Zoloft is better than Luvox,⁸ as are most other SSRIs. There’s not much difference in efficacy as far as Paxil, Lexapro, and Prozac are concerned, although Lexapro generally sucks less than Zoloft, while Zoloft tends to suck less than Paxil and Prozac. One study found if you’re anxious and jittery Zoloft is more likely to work than Prozac, but that was done before everything but Luvox was on the market.

• Zoloft vs. TCAs. As far as efficacy is concerned, there’s not much difference. Zoloft sucks a hell of a lot less, and is far easier to keep taking than TCAs, so taking those into account it’s a clear winner. In fact, the bitching about side effects and difficulty of medication compliance (combing side effects with having to take TCAs 2–3 times a day vs. once a day for Zoloft) is bad enough that one hospital found brand-name Zoloft to be slightly cheaper to use than generic TCAs.
  • Although one study found that Zoloft works better and sucks less for women, while TCAs work better and suck less for men. While nothing actually confirms that, in fact , when I looked at studies with full text or demographic data in the abstracts, combined with some of the reports, I think they might be onto something. At least as far as Zoloft is concerned.
  • Zoloft vs. Tofranil (imipramine) for depression and panic disorder. 138 people took Zoloft, 69 took imipramine. For some reason women outnumbered men 3–1 in this study. The results: a tie. Zoloft sucked a lot less, otherwise the numbers were almost identical.
  • Zoloft vs. Tofranil (imipramine) vs. various personality disorders for chronic major depression. No, I wrote that correctly. Read the self-defeating abstract for yourself and you’ll understand what I mean.
  • Zoloft vs. imipramine for non-melancholic depression. “Non-melancholic” is another term for “exogenous” - depression caused by something in your life and not because your brain is messed up. Although exogenous tends to be out of proportion, but that’s splitting DSM hairs. The results: Zoloft clearly won this one. It was more effective for more people, kept more of them depression-free after they stopped taking it, and sucked a lot less.
  • Zoloft vs. Tofranil (imipramine) for people 60 and older with severe depression. This small study - only 55 people - tracked the geezers for all of 6 weeks. The results: Imipramine was slightly more effective. As to which sucked less, that’s hard to figure out. More people taking imipramine dropped out due to intolerable side effects, but of those who completed the study, imipramine’s side effects sucked less than Zoloft’s.
  • Zoloft vs. imipramine for chronic major depression with anxiety. Two hundred nine people took imipramine and 426 took Zoloft. 36% liked the Mel Brooks movie met criteria for high anxiety. The winner: people with anxiety, as more of them (66% vs. 54%) responded to either med. Otherwise the results were the usual: the two meds work the same, but Zoloft sucks less.
  • Zoloft vs. imipramine to prevent relapse in chronic depression. 635 people were randomized to Zoloft or imipramine in a 2:1 ratio, given 12 weeks to get better and followed up after 16 weeks. Anyone who didn’t get better was given the other med. The results: a tie, except Zoloft sucked less. Gee, couldn’t see that one coming. I found this to be especially funny:
    LIMITATIONS:The absence of a placebo group constrains interpretation of our results, but chronic depressions have low placebo response rates.
  • Zoloft vs. desipramine for depression with OCD. C’mon, desipramine for OCD? Zoloft kicked its ass.
  • Zoloft vs. amitriptyline for depression. 100 people took Zoloft and 105 took amitriptyline for six weeks. I’ll let you guess the results, because you won’t be wrong.
  • Zoloft vs. imipramine vs. men vs. women for chronic major depression. So, does your plumbing make any difference as far as the Zoloft vs. imipramine contest is concerned? It might. 235 men and 400 women took one or the other for 3 months. Zoloft works better and sucks less for women, while imipramine works better, faster, and sucks less for men.
  • Zoloft vs. imipramine vs. placebo for chronic depression - which keeps you from hurting yourself the best? Harm avoidance is apparently overlooked in a lot of studies. I can tell you from personal experience that people who are severely depressed are more than happy to put themselves in dangerous situations as a form of passive suicide. The clear winner here was Zoloft. Imipramine didn’t even beat the placebo.
  • Zoloft vs. imipramine vs. placebo for anger attacks during chronic depression Zoloft vs. imipramine vs. placebo for dysphoric mania in bipolar 2. This is from 1997, they didn’t know about dysphoric mania and bipolar 2. The results: imipramine was somewhat better, which isn’t surprising given how TCAs work.
  • Zoloft vs. clomipramine for depression. Another TCA, another tie. This time the TCA’s side effects didn’t suck all that much more than Zoloft’s.
  • Low dosage Zoloft vs. really low dosage Elavil (amitriptyline) for depression in people with Parkinson’s. At least this tiny study ran for three months. 16 people took 50 mg of Zoloft, 15 took 25 mg of amitriptyline. The results: Pretty much a tie, and neither did squat for the Parkinson’s symptoms.
• Zoloft vs. other meds. This is way too random to pin down.
  • Zoloft vs. reboxetine for depression. This was a small study of 41 people, 20 on reboxetine 21 on Zoloft. The results: Hard to say. Reboxetine is more effective and works faster, but sucks more - the one person who dropped out was in the reboxetine group. By the time the study was done both meds worked for about 80% of the people in each group. Turkish language version of the study is here.
  • Zoloft vs. moclobemide for atypical depression. In this double-blind study 197 people took either Zoloft or the MAOI moclobemide for three months. The results: Zoloft was significantly better. That is surprising, as MAOIs are usually the best meds around for atypical depression. Zoloft worked better (HAM-D score decreased from 35.9 to 14.5 in the Zoloft group vs 36.3 to 16.1 in the moclobemide group) for more people (77.5% vs. 67.5%). Zoloft also worked better for anxiety, sleep, and a few quality of life categories.
  • Zoloft vs. psychotherapy vs. Zoloft and psychotherapy for chronic moderate depression (dysthymia). Although not approved for dysthymia, SSRIs are used for it all the time and it’s close enough. The results: Zoloft alone worked best, followed by Zoloft + therapy. Zoloft alone kicked interpersonal psychotherapy’s ass, but maybe they just like drugs up in Canadia.
  • Zoloft vs. Solian (amisulpride) - which works faster for depression? Solian (amisulpride) is an atypical antipsychotic (AAP) available in Australia, the EU and other European countries, but not the US. In Italy it’s also approved to treat depression. The results: Solian works a lot better a lot faster. It takes Zoloft three months to catch up.
  • Zoloft vs. Valdoxan (agomelatine): which one helps you sleep better in depression with anxiety. Since Zoloft is pretty good at helping people with anxious depression sleep, why not compare it with a melatonin agonist? 154 people took Zoloft, 159 took Valdoxan for six weeks. The results: Valdoxan (not available in the US, or many other places) makes you sleep a hell of a lot better, and that seems to help with depression and anxiety caused or exacerbated by insufficient and/or crappy sleep.
  • Zolft vs. St. John’s Wort for depression. A randomized, double-blind study run by real doctors involving people with real depression. The results: Both were equally effective, but St. John’s Wort sucked less. What? Some herb you can get at Ye Olde Suplement Shoppe works as well as real medicine? Not quite. They didn’t use ground up St. John’s Wort or even random St. John’s Wort extract. They used pharmaceutical-grade Hypericum extract imported from Germany, which is sold in, you know, pharmacies. And while the Hypericum generally sucked less, 4 people were withdrawn from the study by their doctors due to drug-induced side effects, including suicidal ideation and drug-induced mania, compared with one person taking Zoloft. And while the Hypericum sucked less, it didn’t suck that much less, and has side effects comparable to any antidepressant on the market.
  • Here’s another one pitting Zoloft against Hypericum extract. The objective of the study totally gives away the desired outcome, “to demonstrate the non-inferiority of hypericum extract versus sertraline in the treatment of moderate depression.” Right. Give Zoloft to people who aren’t depressed enough to need real medication, and see if Hypericum doesn’t fail when comparing the results. The results being a complete tie, with Hypericum sucking somewhat less.
  • Zoloft vs. extended-release Desyrel (trazodone) for depression. This is a weird one. I didn’t think anyone still used trazodone as a primary antidepressant. Oh, wait, this study was done in Italy. In Europe Desyrel is still used as an actual antidepressant and not just an add-on for sleep, or a sleep aid by itself. 62 people took Zoloft, 60 people took Desyrel (trazodone) XR in this double-blind, double-dummy⁹, 6-week study. The results: a tie. Although people in the trazodone group slept a lot better. Big surprise there.
  • Zoloft vs. Mirapex for depression in people with Parkinson’s. Did these people have a grudge against Zoloft or something? Sure, the people with Parkinson’s didn’t have any movement problems, but still. The results: Mirapex (pramipexole) kicked Zoloft’s ass from Napoli to Pfizer HQ and back.
  • Zoloft vs. Remeron ODT for depression. 345 people in this 8-week long, double-blind study took either Zoloft or the then-new Remeron orally disintegrating tablets (ODT - about the only way you can get Remeron most places these days). The results: Remeron worked faster, but eventually they were equality effective. Zoloft sucked less in what people usually consider the most important AD side effects: weight gain and sexual dysfunction.

For anxiety spectrum disorders:
Although Zoloft tends to work better for anxiety, especially social anxiety, than depression, there aren’t nearly as many comparisons with other meds for anxiety disorders. Probably because Zoloft is better for social anxiety disorder/phobia (SAnD), while all the other meds with approvals to treat anxiety disorders are better than Zoloft.

• Zoloft vs. cognitive behavioral therapy (CBT) for late-life anxiety disorders. The abstract is totally vague. All I know is it lasted a year, and they used the Hamilton Anxiety Rating Scale and Worry Domain Questionnaire. The results: shut-up and give gramps his pills.
• Paxil vs. Zoloft for GAD. This was a tiny (55 people), two-month long, double-blind study. The results: a total tie.
• Zoloft vs. Serzone (nefazodone) for PTSD. Even smaller than above. 37 people took Zoloft or nefazodone for three months. The results: One worked faster, but the abstract isn’t telling me which. Otherwise it was a draw.
• Zoloft vs. Effexor XR vs. placebo for PTSD. 538 people took one of the three for three months. The results: Effexor XR won, sometimes doing much better than Zoloft, sometimes only doing a little better. Placebo did OK.
• Zoloft vs. self-administered cognitive behavior therapy (SCBT) vs. placebo vs. Zoloft and SCBT vs. placebo and SCBT. 251 people were given some permutation of the above for three months. The results: the combination of SCBT and Zoloft was the winner, and everything else didn’t do much good.
• Zoloft vs. cognitive behavioral group therapy (CBGT) for OCD. 28 people took Zoloft, 28 people went to group therapy for three months. The results: therapy kicked Zoloft’s ass. CBGT worked better for more people, including complete remission for 8 people vs. 1 for Zoloft.
• Zoloft vs. habit reversal training (HRT) vs. Zoloft and HRT for trichotillomania. At least someone cared enough about trichotillomania, chronic hair pulling, to do a small study. The abstract is pretty vague, but it looks like only the two combined actually work after 22 weeks.

3.5  For off-label uses:

• Premature ejaculation cage match! Luvox vs. Paxil vs. Prozac vs. Zoloft vs. placebo. Sixty guys with a hair trigger (one minute or less) were given a stopwatch (that probably did wonders for everyone’s mood) and either a placebo or an SSRI for six weeks. The results: Luvox is worthless. While the average for the rest was around two minutes, Paxil worked best, followed by Prozac and Zoloft. I can’t tell if they got to keep the stopwatches, let alone what effect using a stopwatch during sex had on delaying ejaculation.
• Zoloft vs. Celexa for premature ejaculation. 40 men took Celexa and 40 took Zoloft for two months. The results: a tie. They used a scale instead of time, so I have no idea how well each med really worked.
• Topamax works better than Zoloft for nocturnal binge eating, but Zoloft sucks a lot less.
• Zoloft vs. Prozac for binge eating.
• Zoloft vs. nortriptyline for postpartum depression. This study looked specifically at sexual function. The result: a tie.
• Zoloft vs. Prozac for undifferentiated somatoform disorder (USD). 45 people, 28 took Prozac (fluoxetine) 17 took Zoloft. The results: a tie.

4.  Dosage, Titration, and Discontinuation

One of the most important aspects of any medication is how to go about taking it. This includes:

• how much to take (the dosage or dose)
• when and how often to take it (dosing schedule or doses)
• how much to start with and how to increase the dose/dosage until you’re taking the target amount (titration or titration schedule).

This information is always in the PI sheet, is usually in the information for patients leaflets, most doctors will give you some idea of what it will be like, and this is what every pharmacist is trained and paid to tell you.
We here at Crazy Meds often disagree with the official schedules found in the PI sheets. We usually advocate starting at a lower dosage than recommended. One of our core philosophies is increasing the dosages as slowly as one’s condition allows, and staying at the dosage that works instead of a target dosage¹⁰. More and more doctors are agreeing with us¹¹. You and your doctor can always discuss increasing the dosage when you need to in advance.

4.1  Dosage and doses:

• Typically it’s one 25, 50, or 100mg tablet once a day, usually in the morning. Larger tablets are often split in half to save money.
• The Crazy Meds’ suggestion: However many whole and half tablets of any size it takes to get the dosage that works for you, anywhere a range of 12.5 to 100mg a day, in increments of 12.5mg. So that’s 12.5, 25, 37.5 and so forth.
• Zoloft is rated safe up to 200mg a day, and many people take dosages above 100mg a day. The are probably ultra-rapid metabolizers.

4.2  Best time / way to take Zoloft:

• Unless you find it makes you sleepy, take Zoloft in the morning.
• Taking it with food would probably help with any gastro-intestinal problems you might have.
• However, taking Zoloft with food slightly alters its pharmacokinetics. Not enough to affect how much you need to take, but possibly enough to affect how it makes you feel a few hours after you take it, so taking it before or with breakfast might make a difference.
• Just don’t mess around too much with when you take it. Like almost all SSRIs Zoloft has a half-life in the neighborhood of 24 hours, so taking it at the same time each day, give or take an hour, will make your life a lot easier.

4.3  Titration schedule:

In the PI sheet Pfizer recommends:

We suggest:
Everybody starts at 12.5–25mg and waits at least two weeks, if you can, before increasing by 12.5–25mg a day. And increase the dosage only if you need to.

Sure, why not. I have no freaking idea. Girls’ plumbing is complicated. Maybe starting at 25mg like everyone else will work. Try to find an OB/GYN who knows about psych meds or a head doctor who treats PMDD on a regular basis.

4.4  How to discontinue Zoloft:

One thing PI sheets and doctors infrequently discuss, and don’t go into enough detail about, is how to discontinue a medication. With some meds it’s not too bad, but with others it can be a nightmare.
The usual way with SSRIs. Reduce your dosage by 12.5–25mg each week. If the discontinuation syndrome is too harsh you have two options, getting a prescription for the oral concentrate and reducing your dosage by whatever you can tolerate, or getting a prescription for 10mg fluoxetine capsules and take 20–30mg a day (if you’re at 25mg of Zoloft) for two weeks and lowering your dosage by 10mg a day each week.

4.5  Discontinuation symptoms:

The same as with any other SSRI.

4.6  Notes, tips, etc. about discontinuing Zoloft:

If you’re Chinese you can probably get away with taking no more than 25mg a day. At least that’s what they found in this single, small study. And while that is a frequent occurrence with crazy meds, don’t base your insurance plan selection on your ethnicity.

The oral concentrate has some interesting instructions:

Why only ginger ale, lemonade, OJ, and what I guess is 7-Up or Sprite (or generic equivalents)?¹² Did the R&D guys grow up drinking Gin Bucks or something? Furthermore…

OK, that’s easy enough to deal with. At least they warn you. Back to making mixed drinks with Zoloft…

There’s nothing in the literature about it, but I’ve read a few reports and seen it myself, Zoloft makes some people drunker faster. So it seems extra weird to even supply Zoloft in a liquid form if it needs a solution with 12% alcohol to keep the sertraline stable.

5.  Pros, Cons, and Interesting Information

Every med has its good points and its bad points. This is what we think those are.
Doctors don’t have the time to tell you everything about a drug. Patient information leaflets leave out a lot. Even if the PI sheet covers everything the language is so dense and obtuse that the good stuff is often lost in information overload. Most meds have something interesting about them.

5.1  Pros

• The slight, but noticeable, dopamine action Zoloft has is often enough to get you out of bed and back to work within a couple of days. You might still be depressed for another two-four weeks, but at least you don’t have to lie in bed staring at the ceiling and ruminating on how much your life sucks.
• That also makes weight gain less likely.
• Zoloft has the lowest rate of cardiovascular side effects of any antidepressant.

5.2  Cons

• The slight dopamine action Zoloft has makes it the worst Serotonin-[sorta-]Selective Reuptake Inhibitor to take if bipolar is known or suspected.
• Definitely the worst to have taken if your bipolar diagnosis was a surprise.
  • By “the worst” I don’t mean it’s more likely than any other SSRI to trigger mania, that’s the same as all the others. No, by “the worst” I mean you’re more likely to have a dysphoric, smash everything in site, scare the shit out of the kids, have the neighbors call the cops mania instead of a euphoric, max out your credit cards, drive to Vegas and marry a complete stranger mania.
  • Then again, it’s difficult to truly gauge “worst.”
• While the dopamine action is in the right place to make you sweaty and nervous (like Wellbutrin), and to exacerbate insomnia, it’s nowhere near the right place to prevent sexual side effects.

5.3  Interesting stuff your doctor probably didn’t tell you:

If you take the tablets with food you’ll get a 25% increase in Zoloft’s peak plasma - the most you’d have in your blood - and it will happen faster, dropping from 8 hours to 5.5.
If you take the oral concentrate with food you won’t get any more out of it, but it will take longer to reach that peak amount, from 5.9 to 7 hours.
Increased and/or delayed peak plasma when taking meds with food happens all the time. But these numbers only make sense if the volunteers were professional lab rats.

Zoloft is one of the few modern antidepressants (not a TCA or MAOI) where taking a month’s worth all at once could possibly kill you. You’d need a prescription for 150–200mg a day, and the odds are still 99-to-1 against you dying - unless you take other stuff with it, then who knows what the odds are - but it’s still a greater than zero chance.

6.  Side Effects and Pregnancy Category

Potential side effects are used as a rationalization to not take a medication. Many people will stop taking an otherwise working drug because of one or more relatively minor, or often temporary side effects. There may even be ways to counter or mitigate side effects.
It all comes down to a very important question: which sucks less?
No matter what crazy med you take, it will probably make you feel spacey and generally out of it for the first few days (i.e. don’t operate heavy machinery), as well as make you drowsy. Even stimulants can make you drowsy. Zoloft will probably affect your dreams as well, and there’s no way to tell if that will be a temporary or permanent side effect. Don’t be surprised if your stomach and/or other parts of your GI system complain for at least the first few days.

6.1  Typical side effects

Most everyone gets at least one or two of these.

• While Zoloft has the usual side effects for SSRIs - headache, nausea, dry mouth, sweating, insomnia, diarrhea or constipation, and loss of libido - the gastro-intestinal problems are often worse than with other SSRIs.

• You’re also way more likely to have diarrhea than constipation, so Zoloft and IBS aren’t a good match.
• As usual most everything, except the loss of libido, usually goes away within a couple of weeks.

6.2  Uncommon side effects

You may or may not get one or more of these.

• Sweatiness, like really sweaty all the time.
• Although getting a little sweaty isn’t all that odd for an SSRI, Zoloft is a very “nervous” drug, much more so than the others in this class. Zoloft is almost Wellbutrin-like in how it can sometimes make you sweaty, shaky and generally uncomfortable in your own skin.
  
• Which I find hilariously ironic, as Zoloft is approved and fairly effective for panic disorder and social anxiety disorder, and used off-label for generalized anxiety disorder.
• Making the symptoms worse ¹³

6.3  Potentially dangerous side effects:

If you have these, call your doctor ASAP. Or now. Or get the hell off of the Internet and go to the ER. NOW!

• Hyponatremia (electrolyte imbalance, mainly not enough salt) - usually a problem with older people.
• Various liver problems.

6.4  Freaky rare side effects:

You won’t get these. Unless you already have and that’s why you’re here.

• Melanin pigmentation disturbance
• Echolalia
• Priapism
• Persistent genital anesthesia

Hmmm, I wonder if Michael Jackson used to take Zoloft…

6.5  Ways to counter / minimize / mitigate / deal with some side effects

6.6  Pregnancy category

C-Use with caution Expanded pregnancy category explanation.

‹ Bibliography | Zoloft Index | Comprehensive Rundown Page 2 ›

² Generic availability isn't fully harmonized in the EU. Sometimes a drug is available everywhere as a generic, sometimes it's available only in a few member states. We'll provide the best information we have.

³ The term "branded generic" has three meanings:
1) A generic drug produced by a generics manufacturer that is a wholly-owned subsidiary of the company that makes the branded version. E.g. Greenstone Pharmaceuticals makes gabapentin**, and they are owned by Pfizer***, who also own Parke-Davis, the makers of Neurontin.
2) A branded generic is also a generic drug given a 'brand' name by the manufacturer (e.g. Teva's Budeprion), but otherwise has the same active ingredient as the original branded version (Wellbutrin).
3) A branded generic is also a generic drug given a 'brand' name by the manufacturer (e.g. Sanofi-Aventis' Aplenzin, which is bupropion hydrobromide) and uses a salt of the active ingredient that is different from the original branded version and other generics (Wellbutrin, Budeprion and all the others are bupropion hydrochloride). We aren't sure if that really makes a difference or not. The FDA says they're the same thing. As usual, the data are contradictory, but most evidence indicates that the FDA is right and the differences are negligible.
For our purposes a "branded generic name" refers to the second and third definitions. We'll note if any preferred generics are manufactured by the pioneering company's subsidiary.

⁴ Except in Finland, where generic names are sometimes rendered into Finnish. This may happen elsewhere, but I haven't come across anyone else doing it.

⁵ Before Cymbalta (duloxetine) was approved as an antidepressant in the US it was already approved in the EU, but only for stress urinary incontinence and sold under the trade name Yentreve. Duloxetine is now sold in the EU as an antidepressant under the trade name Cymbalta.
A better known, if slightly different example is bupropion. According to the 2007 edition of Mosby's Drug Consult, in the US, Canada and Singapore you can get both Wellbutrin (bupropion) as an antidepressant or Zyban (bupropion) to stop smoking. In Korea, Thailand and most of South America (but not Brazil) you can get bupropion (under various trade names) only as an antidepressant. In Brazil, the EU & UK, Israel, India, Australia and New Zealand it's only available as Zyban to help you stop smoking.

⁶ Assuming you were correctly diagnosed in the first place.

⁷ Keep in mind that according to one study, most drug studies will skew in favor of the med made by the company that sponsored the study.***** That's one of my favorite "no shit Sherlock" studies, although it did help in getting conflicts of interest showing up on papers.
Two additional papers along similar lines are Why Current Publication Practices May Distort Science******* and Why Most Published Research Findings Are False********. So in addition to the books we use as source material, this is why we also factor a lot of anecdotal evidence (personal experience, experiences of people we know, case reports, what people have sent us in e-mail, and what is posted all over the Internet) into our conclusions regarding the likelihood of meds working, the prevalence of various side effects, etc.
While the drug companies are getting a lot more transparent and publishing more data in the PI sheets regarding the results of the clinical trials, they still don't publish how many times a drug failed a clinical trial.********

⁸ This is a prime example of really contradictory data. If Lexapro consistently tests as good as, if not better than Celexa, how can Zoloft be better than Lexapro if Celexa is better than Zoloft?

⁹ If you're looking for an Italian joke, there isn't one. In a "double-dummy" study participants get a mixture of active and inactive product so all the pills are the same size, and everyone gets the same number of pills, and takes the same doses at the same time. That's probably a given, but this is the first time I've seen the term, thus it was explicitly spelled out they actually bothered to do it that way.

¹⁰ Although not everyone has the luxury of stopping at a dosage when the symptoms abate and not increasing it unless the return. Sometimes you just have to keep going up until you reach that target dosage. E.g. you have a history of seizures that haven't yet responded to several medications.

¹¹ Most notably Dr. Edward Faught, founder and Director of the Epilepsy Center, and vice chairman of the Department of Neurology, at the University of Alabama School of Medicine in Birmingham. His article on new antiepileptic drugs in Volume 7 issue 1 of Peer Review in Review stressed starting at low dosages, doing a slow titration, and stopping at the dosage where symptoms were under control. In Topiramate in the treatment of partial and generalized epilepsy****, the one free, full-text article I could find (that's not about geriatric patients), he again stresses the low and slow approach to avoid or lessen most side effects, while still achieving seizure control in the same amount of time.

¹² Because there aren't many lemon sodas or lime sodas on the US market.

¹³ Although making the symptoms worse seems to be something meds that affect the sigma-1 receptors, like Luvox and Zoloft, are more likely to do than other meds.

*Article I, Section 8 of the US Constitution
**Greenstone Pharmaceuticals, makers of gabapentin
***Pfizer, owner of Parke-Davis and Greenstone
****Topiramate in the treatment of partial and generalized epilepsy
*****Drug studies favoring sponsors the study.
******Why Current Publication Practices May Distort Science
*******Why Most Published Research Findings Are False
********unpublished clinical trials

Date created 06 Apr 2011 - 14:28 Page Creator: JerodPoore Last edited by:

Crazy Meds’ Comprehensive Pages on Zoloft is copyright 2011 JerodPoore

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Almost all of the material on this site is by Jerod Poore and is copyright © 2004, 2005, 2006, 2007, 2008, 2009, 2010, 2011, and 2012 Jerod Poore. Except, of course, the PI sheets - those are the property of the drug companies who developed the drugs the sheets are about - and any documents that are written by other people which may be posted to this site will remain the property of the original authors. You cannot reproduce this page or any other material on this site outside of the boundaries of fair use copying without the express permission of the copyright holder. That’s usually me, so just ask first. That means if want to print out a few pages to take to your doctor, therapist, counselor, support group, non-understanding family members or something like that - then that’s OK to just do. Go for it! Please. As long as you include this copyright notice and the following disclaimer, I’m usually cool with it.

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All information on this site has been obtained through our personal experience and the experiences family, friends, what people have reported on various reputable sites all over teh intergoogles, the medications’ product information / summary of product characteristic (PI/SPC) sheets, and from sources that are referenced throughout the site. As such the information presented here is not intended as a substitute for real medical advice from your real doctor, just a compliment to it. You should never, ever, replace what a real doctor tells you with something from a website on the Internet. The farthest you should ever take it is getting a second opinion from another real doctor. Educate yourself - always read the PI/SPC sheet or patient information leaflet (PIL) that comes with your medications and never ever throw them away.
Crazy Meds is not responsible for the content of sites we provide links to. We like them, or they’re paid advertisements, or they’re something else we think you should read to help you make an informed decision about a particular med. Sometimes they’re more than one of those things. But what’s on those sites is their business, not ours.
Very little information about visitors to this site is collected or saved. From time to time I look at search terms used and which pages they bring up in an effort to make the information I present more relevant. And the country of origin, just because I’m geeky like that. That’s about it. Depending on how you feel about Schrodinger, our privacy policy should either assuage or exacerbate your paranoia.
All brand names of the drugs listed in this site are the trademarks of the companies named on the PI/SPC sheet associated with the medication, sometimes on the pages about the drugs, even though those companies may have been acquired by other companies who may or may not be listed in this site by the time you read this. Or the rights to the drug were sold to another company. And any or all of the companies involved may have changed their names.
Crazy Meds is optimized for the browser you’re not using on the platform you wish you had. Between you and me, it all looks a lot cleaner using Firefox or Safari, which is what a plurality of visitors use. And I’m running Windows XP3. On a computer that sits on top of my desk. With a 23 inch monitor. Hey, at least you can make the text larger or smaller by clicking on the + or - buttons in the upper right hand corner. If you have Java enabled. Like 99% of the websites on the planet, Crazy Meds is hosted on domain running an open source operating system with a variety of open source applications, including the software used to display what you’ve been reading. As such Crazy Meds is not responsible for whatever weird shit your browser does or does not do when you read this site².
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¹ While there are plenty of books to help you with hypochondria, for some reason there’s not much in the way of websites. Then again, staying off of the Internet is a large part of curing/managing the disorder.

² Have I mentioned how open source operating systems for commercial applications is one of the dumbest ideas in the history of dumb ideas?
[begin rant] I rent a dedicated server for Crazy Meds. It’s sitting on a rack somewhere in Southern California along with a bunch of other servers that other people have rented. The hardware is identical, but no two machines have exactly the same operating systems. I don’t even need to see what is on any of the others to know this. If somebody got their server at the exact same time, with the exact same features as I did, I’m confident that there would be noticeable differences in some aspects of the operating systems. So what does this mean? For one thing it means that no two computers in the same office of a single company have the same operating system, and the techs can spend hours figuring out what the fuck the problem could be based on that alone. It also means that application software like IP board that runs the forum here has to have so many fucking user-configurable bells and whistles that even when I read the manual I can’t find every setting, or every location that every flag needs to be set in order for a feature to run the way I want it to run. And in the real world it means you can get an MBA not only with an emphasis on resource planning, but with an emphasis on using SAP - a piece of software so complex there are now college programs on how to use it. You might think, “But don’t people learn how to use Photoshop or Adobe Illustrator in college?” Sure, in order to create stuff. And in a way you’re creating stuff with SAP. But do you get a Bachelor of Fine Arts degree with an emphasis on Photoshop?
Back in the Big Iron Age the operating systems were proprietary, and every computer that took up an entire room with a raised floor and HVAC system, and had less storage and processing power than an iPhone, had the same operating system as every other one, give or take a release level. But when a company bought application software like SAP, they also got the source code, which was usually documented and written in a way to make it easy to modify the hell out of it. Why? Because accounting principles may be the same the world over, and tax laws the same across each country and state, but no two companies have the same format for their reports, invoices, purchase orders and so forth. Standards existed and were universally ignored. If something went wrong it went wrong the same way for everyone, and was easy to track down. People didn’t need to take a college course to learn how to use a piece of software.
I’m not against the open source concept entirely. Back then all the programmers read the same magazines, so we all had the same homebrew utilities. We even had the forerunner to QR Code to scan the longer source code. Software vendors and computer manufacturers sponsored conventions so we could, among other things, swap recipes for such add-ons and utilities. While those things would make our lives easier, they had nothing to do with critical functions of the operating system. Unless badly implemented they would rarely cause key application software to crash and burn. Whereas today, with open source everything, who the hell knows what could be responsible some part of a system failing. [/end rant]