Journal of Affective Disorders 102 (2007) 1 – 9

www.elsevier.com/locate/jad

Research report
The sales of antidepressants and suicide rates in Norway
and its counties 1980–2004
Jørgen G. Bramness a , Fredrik A. Walby b,c,⁎, Aage Tverdal a
a
Department of Pharmacoepidemiology, Division of Epidemiology, Norwegian Institute of Public Health, Oslo, Norway
b
The Suicide Research and Prevention Unit, Faculty of Medicine, University of Oslo, Oslo, Norway
c
Diakonhjemmet Hospital, Oslo, Norway
Received 8 November 2006; received in revised form 30 November 2006; accepted 1 December 2006
Available online 16 January 2007

Abstract

Background: Suicide is a major public health problem and depression is among the most important risk factors for suicide.
Treatment of depression might prevent suicide. To study this hypothesis further we conducted an ecological study.
Methods: An ecological study using sales data for antidepressants and numbers of suicides in Norway and Norwegian counties
1980–2004 was performed. Data on alcohol consumption and unemployment rates were registered and taken into account. Data
were analyzed using Cochrane-Orcutt time series for the country as a whole. The county specific data were analyzed with a random
coefficient model with county as subject and intercept and time (slope) as random variables using an unstructured covariance
matrix.
Results: Sales of non-tricyclic antidepressants (non-TCAs) and suicide were clearly negatively related, even when controlling for
alcohol and unemployment (adjusted r2: 0.57). There was an effect modification between time and level of sales of non-TCAs.
Studying the relationship between the sales of non-TCAs and the suicide rate, we found that it was significant and stronger for the
low sales figures, but non-existent for the high sales figures.
Limitations: Ecological studies cannot infer causality.
Conclusions: The fall in suicide rates in Norway and its counties was related to the increased sales of non-TCAs. The effect was
mostly a result of a sales increase in the lower sales segment, indicating that a change from the more toxic TCAs, or heightened
awareness of depression and its treatment, could explain the relationship found between sales of newer antidepressants and a
decrease in suicide rate.
© 2006 Elsevier B.V. All rights reserved.

Keywords: Antidepressant; SSRI; Suicide; Ecological study; Pharmacoepidemiology

1. Introduction

Mental health disorders are important causes of

suicide (Harris and Barraclough, 1997), and particularly
⁎ Corresponding author. The Suicide Research and Prevention Unit,
important are affective disorders, because different
University of Oslo, Sognsvannsveien 21, Bygning 12, 2. etg., NO-
subtypes are found among about 60% of suicides in
0320 Oslo, Norway. Tel.: +47 22 92 34 73; fax: +47 22 92 39 58. the general population (Cavanagh et al., 2003). The risk
E-mail address: fredrik.walby@medisin.uio.no (F.A. Walby). of suicide also increases with the severity of the
0165-0327/$ - see front matter © 2006 Elsevier B.V. All rights reserved.
doi:10.1016/j.jad.2006.12.002
2 J.G. Bramness et al. / Journal of Affective Disorders 102 (2007) 1–9
depressive episode (Kessing, 2004). Treatment of such
conditions is thought to be beneficial in the prevention
of suicide. The introduction of newer antidepressants,
and especially the selective serotonin reuptake inhibi-
tors (SSRIs), at the start of the 1990s accelerated the
diagnosis and treatment of depression. Far more people
were exposed to drugs that could alleviate depression.
Together with this increase in sales of antidepressants,
many western countries experienced a decline in their
national suicide rates. Several researchers, particularly
Isacsson (Isacsson, 2000), have promoted the idea that
these two phenomena are related and increased
treatment of depression has led to the observed decline.
Although suicide is a major public health issue, it is a
rare phenomenon at an individual level. Only very large,
possibly unsustainable, randomized controlled trials
(RCTs) would, by themselves, have enough power to
demonstrate any difference in suicide rate between a
treatment and a placebo. Meta-analysis of such studies
could, to some extent, overcome this (Khan et al., 2003;
Gunnell et al., 2005). The follow-up time of RCTs
included in the meta-analysis is, however, too short to
capture the whole at-risk period for suicide in
connection with depression. Furthermore, suicidality is
usually an exclusion criterion in such trials, because of
ethical constrains and practical difficulties.
Ecological investigations into the relationship be-
tween the sales of newer antidepressants and suicide
rates have been performed in several countries, with
varying time spans, different age groups, and various
types of co-variates and statistical approaches (Table 1).
With the exception of the studies in Iceland, Italy and
Slovenia, which have not shown a decline in suicide
rates, most of these studies find that the increased sales
of newer antidepressants seem to be related to the
decrease in suicide rate. This is also found in other
communications from Hungary (Rihmer et al., 2001;
Rihmer, 2003) and Britain (Gunnell and Ashby, 2004).
What separates them are the result interpretations,
ranging from a belief in a causal relationship to stating
that sales figures are indirect measures of better
diagnosis of depression and more treatment optimism,
or even that the relationship is purely spurious.
The aim of the current study was to investigate the
relationship between antidepressant sales and suicide
rates as seen in Norway as a whole, and in its counties, on
the basis of observations made from 1980 to 2004. As a
completed suicide is not just a matter of mental illness
and its treatment, we also included data on alcohol
consumption and unemployment as confounders, both of
which have been found to be related to national suicide
rates (Rossow, 2005; Platt and Hawton, 2006).
2. Method
2.1. Sources of data
Suicide rates were provided by Statistics Norway.
The figures are given in deaths by suicide per 100,000
inhabitants. Suicide rates were available for the country
as a whole from 1980 to 2004, but only up to 2003 when
dealt with by the county. Statistics Norway also supplied
data on sales of alcohol for the years 1980–2004,
although data from 1998 were missing. Alcohol sales
data were available only for the country as a whole.
Figures are given in liters of pure ethanol sold through
official channels per person in Norway (all ages).
Unemployment figures were taken as a proxy for the
state of the economic climate, and were provided by the
Norwegian employment agency through Statistics Nor-
way. These data were available for 1980–2004 across
counties. The figures are presented as the number of
people registered unemployed as a percentage of the
total population.
Drug sales data were taken from the wholesale
register at the Norwegian Institute of Public Health. All
data were per county and calendar year for the years
1980–2003. County-specific data for 1981 were not
available. Data on wholesale figures for drugs were
collected from all drug wholesalers in Norway, and
represent total sales to pharmacies, institutions, etc. Even
if these data were complete, drugs sold are not of course
necessarily consumed. However, for the purpose of
comparing regions or countries, and looking for trends,
these figures will probably provide reliable information.
All drugs on the Norwegian market are classified into
groups according to the Anatomical Therapeutic Chem-
ical (ATC) classification. The sales figures were
calculated and presented as numbers of defined daily
doses (DDDs)/1000 inhabitants per day at the group
level for the active ingredient (ATC fourth or fifth level)
(WHO Collaborating Centre for Drug Statistics Meth-
odology, 2005). Sales figures were calculated for the
following groups of drugs: tricyclic antidepressants
(TCAs) (ATC code N06AA: desipramine, imipramine,
clomipramine, opipramol, trimipramine, amitriptyline,
nortriptyline and doxepin), selective serotonin reuptake
inhibitors (SSRIs) (N06AB: fluoxetine, citalopram,
paroxetine, sertraline, fluvoxamine and escitalopram)
and other antidepressants (N06AG: moclobemide and
N06AX: mianserin, nefazodone, mirtazepine, venlafax-
ine and reboxetine). In the analysis all these sales figures
were either grouped together (all antidepressants) or the
SSRIs and other antidepressants were grouped together
as the non-TCAs.
 J.G. Bramness et al. / Journal of Affective Disorders 102 (2007) 1–9 3

Table 1
Ecological studies addressing the relationship between sales of antidepressants (ADs) and suicides rates in different countries and by different models
Reference Years studied Study area Co-variates in addition Statistical methods Main findings
to ADs
Barbui et al. 1988–1996 Italian regions Gender Suicide rates Increase in SSRI sales gave higher
(1999) plotted against AD sales, but no effect on suicide rate
AD sales
Carlsten et al. 1977–1997 Sweden Age, gender Time series two A significant change in suicide rate
(2001) slope model coincided with the introduction of
SSRIs, but preceded the high increase
in SSRI sales
Gibbons et al. 1996–1998 5–14 year olds, USA Age, gender, Mixed effect Increases in prescriptions for non-TCAs
(2006) county comparison income, race Poisson regression were associated with lower suicide
rates between counties and over time
Gibbons et al. 1996–1998 USA county Age, gender, Mixed effect Increases in prescriptions for non-TCAs
(2005) comparison income, race Poisson regression were associated with lower suicide
rates between counties and over time
Grunebaum 1985–1999 USA Unemployment, alcohol Generalized linear Decline in national suicide rates
et al. consumption model are associated with sales of non-TCAs
(2004)
Guaiana et al. 1955–2000 Italy Gender Descriptive The increase in AD sales did not
(2005) explain the decrease in suicide rate
Hall et al. 1991–2000 Australia Age, gender Spearman's rank Changes in suicide rates and exposure
(2003) correlation to ADs are significantly associated
Helgason et al. 1950–2000 Iceland Alcohol consumption, Quasi-Poisson Increased prescribing of ADs is not
(2004) psychiatric admissions model related to lower suicide rates
and outpatient visits,
disability pension
Henriksson 1990–1994 vs Sweden, one county Sales of ADs Descriptive AD sales increased and suicide
and Isacsson 1995–2002 rates decreased in context of GP
(2006) educational program
Kelly et al. 1989–1999 Ireland Unemployment rate, Linear regression Increased antidepressant prescribing
(2003) alcohol expenditure, effective in reducing suicides
terrorist offences
Isacsson 1978–1996 Sweden (compared Age, gender, Spearman's The increased use of ADs appears
(2000) with Denmark, unemployment rates, correlation to be associated with the decrease
Norway and Finland) alcohol consumption coefficient in suicide rate
Ludwig and 1980–1999 26 European GPD/capita, divorce Logistic regression The increased sales of SSRIs may
Marcotte (every countries (including and unemployment rate with fixed effects have saved lives
(2005) 5 years) Norway) and the
USA
Morgan et al. 1993–2002 England AD-related deaths Spearman's rank Increased prescribing of ADs is
(2004) correlation accompanied by lower suicide rates
Olfson et al. 1989 vs 2000/ 10–19 year olds in Age, gender, Adjusted linear An inverse relationship between
(2003) 2001 US regions income and race regression sales and suicide rates raises a
possibility for suicide prevention
effect of ADs
Oravecz et al. 1985–1997 Slovenia Correlations No correlation was found between
(2003) sales of antidepressants and suicide rate
Reseland et al. 1961–2001 Norway, Sweden, Joint point analysis Mixed evidence that SSRI sales
(2006) Denmark, Finland coincide with decline in suicide rate
GDP, gross domestic product; SSRIs, selective serotonin reuptake inhibitors; TCAs, tricyclic antidepressants.

2.2. Statistical analysis
2.2.1. Model for sales of antidepressants
The relationship between suicide rate and antide-
pressant sales was studied using a random coefficient
model, with county as subject, sales of antidepressants
and time as fixed effects and intercept and time (slope)
as a random effect using an unstructured covariance
matrix. The antidepressant group used for further analy-
sis was chosen on the basis of the lowest value for the
Akaike information criterion (AIC) (Lindsey and Jones,
1998).
4 J.G. Bramness et al. / Journal of Affective Disorders 102 (2007) 1–9

Fig. 1. Relationship between suicide rate (deaths in suicide per 100,000 inhabitants per year) and sales of non-tricyclic antidepressants (defined daily
doses or DDDs/1000 inhabitants per day) in Norway, 1980–2004.

2.2.2. The whole country 3. Results

For the country as a whole we performed a Cochrane-
Orcutt time series analysis (Cochran and Orcutt, 1949).
Models were run with antidepressants, alcohol consump-
tion and unemployment rates as independent variables.
The regression coefficient (β) with 95% confidence
interval (95% CI) and the ability of the independent
variables to explain variation in the dependent variable
(R2) was calculated.
2.2.3. The 19 counties
When studying the 19 different counties of Norway, a
random effect model was used with county as subject,
suicide rates in counties as the dependent variable, sales of
antidepressants, unemployment rates and time as fixed
effects, and intercept and time (slope) as random effects
using an unstructured covariance matrix. We did not have
alcohol figures for each county and the analyses were
performed without this variable. We checked for interac-
tions between two and two variables (time ⁎ AD sales,
time ⁎ unemployment rates and AD sales ⁎ unemployment
rates) adding one interaction to the mixed model at a time.
3.1. Model for sales of antidepressants
Three models using drug sales figures as independent
variables and suicide rate as dependent variable were
used:
1. The relationship between suicide rates and sales fig-
ures for all antidepressants.
2. The relationship between suicide rates and sales
figures for non-TCAs.
3. The relationship between suicide rates and sales
figures for SSRIs.
Only the main effects were studied. The model
giving the best fit was option 2: the relationship
between suicide rate and sales of non-TCAs. We
chose this model because it produced the lowest AIC
value, even if the differences between the models
were moderate (Raferty, 1995). Model 2 was therefore
used throughout.

Table 2
Cochrane-Orcutt statistics for the relationship between the dependent variable of national suicide rate and the independent variables of sales of non-
tricyclic antidepressants (non-TCAs), alcohol consumption and unemployment rate in the whole of Norway, 1980–2004
Crude p value R2 Adjusted a p value R2
Regression coefficient (95% CI) Regression coefficient (95% CI)
Sales of non-TCAs − 0.090 (− 0.136 to − 0.042) 0.001 0.47 − 0.105 (− 0.180 to − 0.028) 0.010
Alcohol consumption − 1.239 (− 2.712 to 0.393) 0.129 0.12 0.402 (− 2.541 to 3.346) 0.774 0.57
Unemployment figures − 0.161 (− 1.450 to 1.126) 0.797 0.00 − 0.298 (− 1.806 to 1.228) 0.689
a
Adjusted for sales of non-TCA antidepressants, alcohol consumption, unemployment figures and time.
 J.G. Bramness et al. / Journal of Affective Disorders 102 (2007) 1–9 5

Fig. 2. Relationship between suicide rate (deaths in suicide per 100,000 inhabitants per year) and sales figures for alcohol (liters of pure alcohol per
inhabitant) in Norway, 1980–2004. Figures for 1998 could not be obtained.

3.2. The whole country
The Cochrane-Orcutt statistics showed that the sales
of non-TCAs were related to suicide rate (Fig. 1), even
when adjusting for alcohol consumption, unemployment
rate and time (Table 2). Alcohol consumption (Fig. 2)
and unemployment rate (Fig. 3) were not significantly
related to suicide rate (Table 2).
3.3. Norwegian counties
Using a random coefficient model, we also found an
inverse relationship between suicide rates and sales
figures for non-TCAs when the analysis was performed
using all 19 Norwegian counties. We had no alcohol
consumption data at a county level, but the inverse
relationship between suicide rates and sales figures was
clearly present after an adjustment for unemployment
rate (Table 3).
When performing the analysis on the relationship
between sales of non-TCAs and suicide rate at a county
level, the interaction between sales of non-TCAs and
time was significant (estimate fixed effect = 0.049, 95%
CI = 0.009–0.089, p = 0.018), indicating that the rela-
tionship between sales of non-TCAs and suicide rate
was different at different times. To further address this
interaction, we performed an analysis at the county level
after stratifying the sales figures of antidepressants into

Fig. 3. Relationship between suicide rate (deaths in suicide per 100,000 inhabitants per year) and unemployment rates (number of registered
unemployed per 1000 inhabitants) in Norway, 1980–2004.
6 J.G. Bramness et al. / Journal of Affective Disorders 102 (2007) 1–9
Table 3
The relationship between sales of non-TCAs, unemployment rate and suicide rate in Norwegian counties 1980–2003 using a random coefficient
model with county as subjects, suicide rate as dependant variable, sales of antidepressants, unemployment rate and time as fixed effects and intercept
and time (slope) as random effects
Crude
Estimate for fixed effects (95% CI)
Sales of non-TCAs −0.136 (− 0.174 to − 0.097)
Unemployment figures 0.834 (0.341 to 1.328)
Low sales of non-TCAs
Sales of non-TCAs −0.462 (− 0.635 to − 0.290)
Unemployment figures −0.279 (− 1.097 to 0.538)
High sales of non-TCAs
Sales of non-TCAs −0.024 (− 0.130 to 0.081)
Unemployment figures −0.560 (− 1.689 to 0.568)
a
Adjusted for sales of non-TCAs, unemployment figures and time.
low and high sales of non-TCAs, according to whether
the sales were lower or higher than the mean sales of 16
DDDs/1000 inhabitants per day. These analyses showed
that the relationship between sales of non-TCAs and
suicide rates was significant and stronger for the low
sales figures, but non-existent for the high sales figures
(Table 3). To check for other possible explanations for
this interaction the same analyses were also performed
for different counties (low versus high sales counties) or
different time periods (early versus late time period).
The interaction was not explained by differences
between high and low sales counties or between early
years (with low sales) and later years (with higher sales).
4. Discussion
This ecological study of the increase in sales of
antidepressants and fall in suicide rate in Norway and its
counties found a clear, statistically significant associa-
tion between these two variables. Suicide rates seemed to
fall mostly in association with an increase in the sales of
non-TCAs. The relationship was prominent for sales
figures that were below average, and not for higher sales
figures, indicating that an initial increase in sales was
related more to a decrease in suicide rate. Adjustment for
alcohol consumption and unemployment rates, which
have both been reported to be associated with suicide rate
in other studies, did not alter the relationship.
The magnitude of the effect would be that an increase
in the sales of non-TCAs by 12–13 DDDs/1000 inhab-
itants per day could save one suicide per 100,000
inhabitants. However, when considering only the low
sales figures, the impact would be that an increase of
only about 2 DDDs in the sales of non-TCAs would
save one suicide per 100,000 inhabitants per year. For
p value Adjusted a p value
Estimate for fixed effects (95% CI)
b0.001 −0.159 (− 0.210 to − 0.108) b0.001
0.001 −0.409 (− 1.025 to 0.206) 0.192
b0.001 −0.466 (− 0.639 to − 0.293) b0.001
0.502 −0.382 (− 1.165 to 0.401) 0.337
0.643 −0.026 (− 0.135 to 0.083) 0.631
0.328 −0.584 (− 1.718 to 0.549) 0.310
many counties, and for the country as a whole, this
increase came soon after the introduction of non-TCAs
at the start of the 1990s. It could be that the change from
the more toxic TCAs was beneficial, or that groups not
previously treated, despite clear depression, were now
more likely to receive treatment for depression. The
increased awareness and treatment optimism among
general practitioners (GPs) could also have had an
impact. From the mid-1990s, there has been a marked
increase in alcohol consumption, with no corresponding
increase in suicide rate. The relationship between
alcohol use, antidepressant sales and suicide rates may
have obscured any relation between antidepressant sales
and suicide rates from that point on.
Ecological studies cannot infer causality. In the study
of the public health impact of increased sales of
antidepressants it may still be the best type of study
obtainable. As suicide is a relative rare event, even in
patients treated for depression (Gunnell et al., 2005;
Simon et al., 2006), it could be difficult to conduct
sufficiently large RCTs to investigate the relationship
between suicide and antidepressant treatment. The
problem of statistical power may be overcome by meta-
analysis of RCTs. Two such comprehensive meta-analysis
(Khan et al., 2003; Gunnell et al., 2005) reported no
impact on suicide rate of active treatment and possibly an
increase in self-harm in the treated patients. This increase
may be attributable to the known clinical phenomenon of
increased suicide risk associated with increased psycho-
motor activity, together with continuing depression in the
first weeks after starting antidepressant therapy, or the
induction of manic episodes in patients with bipolar
disorder (Rihmer and Akiskal, 2006) and should probably
not be regarded as evidence against the over all effect of
antidepressants. On the other hand RCTs provide data on
 J.G. Bramness et al. / Journal of Affective Disorders 102 (2007) 1–9
an individual level and may pick up smaller effects than
ecological studies, such as increased suicidality at the
onset of treatment. Then again, even if meta-analyses may
solve the problem of statistical power, most RCTs are too
short to be able to predict the public health benefit of
antidepressant treatment in the longer term. These factors
may explain the possible discrepancy between RCTs and
ecological studies.
Factors other than sales of antidepressants may explain
the observed relationship. Such factors could be better
diagnosis of depression and more treatment optimism
among healthcare professionals. This is supported by
earlier research. The Gotland study demonstrated that
education directed at GPs rather than psychiatrists had an
effect (Rihmer et al., 1995; Rutz, 2001). GPs see most of
the depressed patients and prescribe most of the dispensed
antidepressants. The effects seen in the Gotland study
came at a time when the older antidepressants were still
being used. Our findings indicate that the effect of
increased antidepressant treatment was more pronounced
when sales figures for antidepressants were low. Increas-
ing the sales at this time point probably meant offering
treatment to the individuals with the most apparent
depression. There seems to be a dose–response relation-
ship between severity of depression and suicide risk
(Kessing, 2004), and the early increase might represent
antidepressants being given mainly to those with the most
severe depression. The relationship was not present when
sales were increased beyond a certain level, indicating no
effect when more marginal groups had been offered
treatment. We must bear in mind that we used suicide as
an outcome and that results may differ using other mental
health outcomes.
Suicide prevention plans have been offered as another
explanation for the decline in suicide trends in many
western countries. Such a national suicide prevention
plan was implemented in Norway during 1994–2002,
and could possibly provide an alternative explanation for
our findings. However, the effect of national suicide
prevention plans lacks sufficient evidence (De Leo,
2002). A recent systematic review of suicide prevention
strategies indicated that GP education was one of the
most powerful interventions for preventing suicide
(Mann et al., 2005). It is reasonable to believe that GP
education given at the time of introduction of newer
antidepressants was important in increasing awareness
of depression as a problem.
In our study, we control for a few important co-
variates that were thought to be related to suicide rates.
Alcohol consumption has been shown, in some but not
other studies, to be related to national suicide trends
(Sher, 2005). In the current study we were not able to
7
reproduce earlier results from Norway that indicated a
increase in suicide rate coinciding with increasing sales
in alcohol from 1975 to 1988 (Rossow, 1995). This
illustrates the dilemma of ecological studies. We cannot
refute the earlier studies, only accept the current results
as additional information. The discrepancies in the
results could possibly be explained by the sharp increase
in alcohol consumption after 1993 (Fig. 2), together
with the steady decline in suicide rates. It is also possible
that increased rates of antidepressant sales have protect-
ed against the increased suicide rates expected with
increased alcohol consumption, given that, in the
general population, the combination of depression and
alcohol abuse or dependence seems to be a potent risk
factor for suicide (Cavanagh et al., 2003). The limitation
within the data may also be an explanation, because the
official sales statistics for alcohol are only an indicator
of what is consumed. Much alcohol will be bought tax
free abroad or come from illegal sources.
Our study has the advantage of covering a long time
span (1980–2003), although not the longest of the cited
studies (Table 1). There is a tendency for the studies
including the longest time series (Italy and Iceland) not
to have found any relationship between sales figures and
suicide rate, mostly as a result of stable suicide rates
despite increases in antidepressant sales (Barbui et al.,
1999; Helgason et al., 2004; Guaiana et al., 2005). In
some of the countries without a relationship between
sales of antidepressant sales and suicide rate there was
only little increase in antidepressant sales (Barbui et al.,
1999; Oravecz et al., 2003), offering an explanation to
the conflicting results. In the current study we found a
relationship also with a longer observation period, but
the largest effect seemed to be related to the introduction
of non-TCAs.
Lastly, the observed relationship could be a spurious
finding. Researchers have argued that suicide rates will
vary over time for many unknown reasons (Gmel et al.,
1998). In times of declining suicide rates, credit for this
change will be taken by different interventions. The
Gotland study has been criticized from this point of view
(Berglund et al., 2001). When looking at the relationship
between sales of newer antidepressants and suicide
rates, choosing other time windows and other regions
may also make the relationship disappear (Kahn et al.,
1992). Both in Norway (Reseland et al., 2006) and in
Sweden (Isacsson, 2000; Carlsten et al., 2001), there
was a remarkable drop in suicide rates at the start of the
1990s, coinciding with the introduction of SSRIs.
Ecological studies cannot prove that a drop in suicide
rates is related to increased treatment of depression. On
the other hand, many ecological studies from different
8 J.G. Bramness et al. / Journal of Affective Disorders 102 (2007) 1–9
countries, covering different time periods, using various
statistical approaches and including different confoun-
ders, may be interpreted as increased support for the
prevention effect of antidepressants on rates of suicide.
The current study, covering a long time span and using
adequate statistical approaches, adds to the previous
studies that point to a possible relationship.
5. Conclusion
The fall in suicide rates in Norway and its counties
was related to the increased sales of non-TCAs. The
effect was mostly the result of a sales increase in the
lower sales segment, indicating that an explanation
might be a change from the more toxic TCAs or height-
ened GP awareness of depression and its treatment.
Acknowledgements
This work was performed without any external
source of finance. The authors would like to thank
Berit Olsen and Tove Granum at the Norwegian Institute
of Public Health for the help in collecting the wholesale
data on drugs.
Conflicts of interest: JGB and AT do not have any
commercial associations that might pose a conflict of
interest in connection with the manuscript. FAW has
received an honorarium from Pfizer and H. Lundbeck
for lectures on suicide prevention in general.
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