Antidepressant Deprescribing
Maudsley hyperbolic taper schedules (faster / moderate / slower)
Sertraline — Moderate taper
up to 5 percentage points of SERT occupancy per step · reductions every 2–4 weeks · approx 10–20 months
Dataset values not yet independently re-verified — confirm doses against the source.
| Date | Step | Dose | How | SERT % |
|---|---|---|---|---|
| 2026-10-12 | 1 | 200 mg | Use tablets | 89% |
| 2026-11-02 | 2 | 100 mg | Use tablets | 85% |
| 2026-11-23 | 3 | 75 mg | Use tablets | 83% |
| 2026-12-14 | 4 | 50 mg | Use tablets | 80% |
| → switch to sertraline 20mg/mL liquid | ||||
| 2027-01-04 | 5 | 40 mg | 2mL | 77% |
| 2027-01-25 | 6 | 32 mg | 1.6mL | 73% |
| 2027-02-15 | 7 | 25 mg | 1.25mL | 70% |
| 2027-03-08 | 8 | 19 mg | 0.95mL | 65% |
| 2027-03-29 | 9 | 15 mg | 0.75mL | 60% |
| 2027-04-19 | 10 | 12 mg | 0.6mL | 56% |
| 2027-05-10 | 11 | 9.8 mg | 0.49mL | 51% |
| 2027-05-31 | 12 | 8 mg | 0.4mL | 46% |
| → switch to sertraline 2mg/mL dilution | ||||
| 2027-06-21 | 13 | 6.5 mg | 3.25mL | 42% |
| 2027-07-12 | 14 | 5.3 mg | 2.65mL | 37% |
| 2027-08-02 | 15 | 4.3 mg | 2.15mL | 33% |
| 2027-08-23 | 16 | 3.4 mg | 1.7mL | 28% |
| 2027-09-13 | 17 | 2.6 mg | 1.3mL | 23% |
| 2027-10-04 | 18 | 2 mg | 1mL | 19% |
| 2027-10-25 | 19 | 1.4 mg | 0.7mL | 14% |
| 2027-11-15 | 20 | 0.9 mg | 0.45mL | 9% |
| 2027-12-06 | 21 | 0.4 mg | 0.2mL | 5% |
| 2027-12-27 | 22 | STOP | 0% | |
Formulations
- Tablets: 25, 50, 100 mg (UK, Europe, USA; 50 & 100 mg also Australia)
- Capsules: 25, 50, 100 mg (Canada)
- Liquid: 20 mg/mL oral concentrate (USA, 60 mL; UK 100 mg/5 mL = 20 mg/mL, 60 mL)
- Dilutions: doses ≥4 mg → 20 mg/mL; 0.4–<4 mg → 2 mg/mL (0.5 mL concentrate + 4.5 mL water/juice); <0.4 mg → 0.2 mg/mL (0.5 mL concentrate + 49.5 mL)
- Off-label: tablets disperse in water in 1–5 min — e.g. a 1 mg/mL suspension from a 50 mg tablet in 50 mL; shake, use immediately, discard remainder
Deprescribing notes
- Every-other-day dosing is not recommended for tapering — sertraline's ~26 h half-life causes large plasma swings that can trigger withdrawal.
- Make each reduction only after withdrawal symptoms from the previous one have largely resolved; symptoms should be tolerable and last at most a couple of weeks.
- Intermediate steps halfway between listed doses may be added for a gentler taper; microtapering (small daily reductions) is another option.
- For longer-term users the interval may be shortened to 1 week if the first reductions cause no withdrawal — but never shorter than 1 week (relapse risk).
Cautions
- These regimens are examples, not prescriptions — modify to keep withdrawal tolerable; prioritise the patient's experience over the schedule.
- If severe withdrawal occurs, return to the last tolerated dose, wait for resolution, then taper more slowly.
Half-life ~26 hours · peak plasma 4.5–8.4 hours. Source: Horowitz & Taylor, The Maudsley Deprescribing Guidelines (2024) — Ch.2 — Tapering Guidance for Specific Antidepressants: Sertraline (pp. 263–269). These regimens are examples to adapt to the patient, not fixed prescriptions.
Fluoxetine-equivalent doses (Hayasaka 2015)
Sertraline 100 mg/day ≈ fluoxetine 40 mg/day
high evidence
A reference point, not a switch starting dose. Doses are anchored to fluoxetine 40 mg/day. Values are statistical weighted means from flexible-dose trials — an approximate reference point for comparing agents, NOT a prescribable starting dose when switching (a cross-taper typically starts lower). Round and individualise. Citalopram and duloxetine are not included — Hayasaka reported no value for them.
Fluoxetine-equivalent reference — Hayasaka 2015
| Drug | ≈ fluoxetine 40 mg | Class | Evidence |
|---|---|---|---|
| Agomelatine | 53.2 mg | melatonergic (atypical) | high evidence |
| Amitriptyline | 122.3 mg | TCA | high evidence |
| Bupropion | 348.5 mg | NDRI (atypical) | moderate evidence |
| Clomipramine | 116.1 mg | TCA | moderate evidence |
| Desipramine | 196.3 mg | TCA | high evidence |
| Dothiepin / Dosulepin | 154.8 mg | TCA | moderate evidence |
| Doxepin | 140.1 mg | TCA | moderate evidence |
| Escitalopram | 18 mg | SSRI | low evidence |
| Fluoxetine | 40 mg | SSRI | high evidence |
| Fluvoxamine | 143.3 mg | SSRI | moderate evidence |
| Imipramine | 137.2 mg | TCA | high evidence |
| Lofepramine | 250.2 mg | TCA | low evidence |
| Maprotiline | 118 mg | tetracyclic | high evidence |
| Mianserin | 101.1 mg | tetracyclic | low evidence |
| Mirtazapine | 50.9 mg | NaSSA (atypical) | moderate evidence |
| Nefazodone | 535.2 mg | SARI (atypical) | high evidence |
| Nortriptyline | 100.9 mg | TCA | low evidence |
| Paroxetine | 34 mg | SSRI | high evidence |
| Reboxetine | 11.5 mg | NRI (atypical) | moderate evidence |
| Sertraline | 98.5 mg | SSRI | high evidence |
| Trazodone | 401.4 mg | SARI (atypical) | moderate evidence |
| Venlafaxine | 149.4 mg | SNRI | high evidence |
Anchored to fluoxetine 40 mg/day. Source: Hayasaka et al., J Affect Disord 2015;180:179–184, Table 1. Citalopram and duloxetine are not shown — Hayasaka reported no value. Moclobemide (575 mg in Hayasaka) is not included. Switching strategy (cross-taper, washout, MAOI rules) is on the Switch tab.
Cross-taper / washout strategy + safety rules (NEJM)
Paroxetine → Sertraline
Strategy
Same class (SSRI) — a direct switch (stop Paroxetine, start Sertraline the next day at a low-to-moderate dose) or a brief cross-taper is commonly used. Individualise to the patient.
Both agents are serotonergic — during any overlap, watch for serotonin syndrome (agitation, confusion, fever, tremor).
Safety
- Paroxetine is prone to discontinuation syndrome — taper it down slowly (flu-like symptoms, insomnia, nausea, imbalance, sensory disturbance) rather than stopping abruptly. NEJM
- Overlapping two serotonergic agents (as in a cross-taper) raises the risk of serotonin syndrome — watch for agitation, confusion, fever and tremor. NEJM
Switching to or from an MAOI (phenelzine, tranylcypromine, isocarboxazid, selegiline) requires a drug-free washout — ≥2 weeks in most cases, and 5 weeks after stopping fluoxetine — to avoid serotonin syndrome or hypertensive crisis (per FDA product labeling). This tool does not plan MAOI switches; consult the specific product labels.
Strategy is general guidance — switching is individualised, not a fixed protocol. Facts: Park & Zarate, NEJM 2019;380:559–568 (Table 2); MAOI washout per FDA labeling. Values not yet independently re-verified — confirm before charting.