Holocaust exposure and subsequent suicide risk: a population-based study

  • Cendrine Bursztein Lipsicas
  • Itzhak Levav
  • Stephen Z. Levine
Original Paper

Abstract

Objectives

To examine the association between the extent of genocide exposure and subsequent suicide risk among Holocaust survivors.

Methods

Persons born in Holocaust-exposed European countries during the years 1922–1945 that immigrated to Israel by 1965 were identified in the Population Registry (N = 209,429), and followed up for suicide (1950–2014). They were divided into three groups based on likely exposure to Nazi persecution: those who immigrated before (indirect; n = 20,229; 10%), during (partial direct; n = 17,189; 8%), and after (full direct; n = 172,061; 82%) World War II. Groups were contrasted for suicide risk, accounting for the extent of genocide in their respective countries of origin, high (>70%) or lower levels (<50%). Cox model survival analyses were computed examining calendar year at suicide. Sensitivity analyses were recomputed for two additional suicide-associated variables (age and years since immigration) for each exposure group. All analyses were adjusted for confounders.

Results

Survival analysis showed that compared to the indirect exposure group, the partial direct exposure group from countries with high genocide level had a statistically significant (P < .05) increased suicide risk for the main outcome (calendar year: HR 1.78, 95% CI 1.09, 2.90). This effect significantly (P < .05) replicated in two sensitivity analyses for countries with higher relative levels of genocide (age: HR 1.77, 95% CI 1.09, 2.89; years since immigration: HR 1.85, 95% CI 1.14, 3.02). The full direct exposure group was not at significant suicide risk compared to the indirect exposure group. Suicide associations for groups from countries with relative lower level of genocide were not statistically significant.

Discussion

This study partly converges with findings identifying Holocaust survivors (full direct exposure) as a resilient group. A tentative mechanism for higher vulnerability to suicide risk of the partial direct exposure group from countries with higher genocide exposure includes protracted guilt feelings, having directly witnessed atrocities and escaped death.

Keywords

Suicide Genocide Holocaust Epidemiology 

Notes

Acknowledgements

This study is part of a larger project on the psychiatric aftermath of the Holocaust jointly supported by non-overlapping funds from the Claims Conference and Israel Science Foundation. Through recovering the assets of the victims of the Holocaust, the Claims Conference enables organizations around the world to provide education about the Shoah and to preserve the memory of those who perished. In addition, this research was supported by the Israel Science Foundation (Grant No. 130/13). This work may or may not reflect the views of these funding bodies. Neither funding body provided feedback on this manuscript or were involved in the promotion or design of the study. We thank Professor Yehuda Bauer who clarified the years of increased/onset of persecution of Jews per country. The Ministry of the Interior facilitated the identification of the study population and causes of death and the Central Bureau of Statistics provided the socioeconomic status information.

Compliance with ethical standards

Ethical standards

The Institutional Review Board at the University of Haifa, Israel, approved linking the study data sources without informed consent. Common unique identification numbers were encrypted prior to receiving the data to ensure participant anonymity and confidentiality.

Conflict of interest

Dr. Levav and Dr. Bursztein Lipsicas report no disclosure. In unrelated work, Dr. Levine has received research support and/or consultancy fees and/or travel support from Maccabi Healthcare Services, F. Hoffmann-La Roche, Shire Pharmaceuticals and Eli Lilly.

Supplementary material

127_2016_1323_MOESM1_ESM.docx (17 kb)
Supplementary material 1 (DOCX 17 kb)

References

  1. 1.
    Lemkin R (1944) Axis rule in occupied Europe: laws of occupation, analysis of government, proposals for redress. Carnegie Endowment for International Peace, Division of International Law, Washington, DCGoogle Scholar
  2. 2.
    Lippman M (1998) The convention on the prevention and punishment of the crime of genocide: fifty years later. Ariz J Int Comp Law 15:415–426Google Scholar
  3. 3.
    IPHAP (2016) Acts of genocide committed since the adoption of the convention on the prevention and punishment of the crime of genocide in 1951. http://www.ipahp.org/index.php?en_acts-of-genocide. Accessed 28 Mar 2016
  4. 4.
    Rubanzana W et al (2015) Exposure to genocide and risk of suicide in Rwanda: a population-based case-control study. J Epidemiol Community Health 69(2):117–122CrossRefPubMedGoogle Scholar
  5. 5.
    Bauer J (1992) History of the Holocaust. Franklin Watts, New YorkGoogle Scholar
  6. 6.
    Levav I (1998) Individuals under conditions of maximum adversity: the Holocaust. In: Dohrenwend BP (ed) Adversity, stress, and psychopathology. Oxford University Press, New York, pp 13–33Google Scholar
  7. 7.
    Eitinger L, Krell R, Rieck M (1985) The psychological and medical effects of concentration camps and related persecutions on survivors of the Holocaust: a research bibliography. University of British Columbia Press, VancouverGoogle Scholar
  8. 8.
    Dawidowicz LS (1986) The war against the Jews, 1933–1945. Bantam Books, New YorkGoogle Scholar
  9. 9.
    Sicron M (1957) Immigration to Israel, 1948–1953. Falk Project for Economic Research in IsraelGoogle Scholar
  10. 10.
    World Health Organization (2016) WHO suicide data. http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/. Accessed 21 Mar 2016
  11. 11.
    Haklai Z (2016) Suicide in Israel: suicide 1981–2013, suicide attempts 2004–2014. Department of Information and Evaluation Jerusalem, IsraelGoogle Scholar
  12. 12.
    Levav I (2015) In: Lindert J, Levav I (eds) The aftermath of the European and Rwandan genocides in violence and mental health: its manifold faces. Springer, The Netherlands, pp 303–340Google Scholar
  13. 13.
    Levine SZ et al (2016) Genocide exposure and subsequent suicide risk: a population-based study. PLoS One 11(2):e0149524CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Williams KD (2007) Ostracism. Annu Rev Psychol 58:425–452CrossRefPubMedGoogle Scholar
  15. 15.
    Pat-Horenczyk R et al (2013) Relational trauma in times of political violence: continuous versus past traumatic stress. Peace Confl 19(2):125–137CrossRefGoogle Scholar
  16. 16.
    Solomon Z, Prager E (1992) Elderly Israeli Holocaust survivors during the Persian Gulf War: a study of psychological distress. Am J Psychiatry 149(12):1707–1710CrossRefPubMedGoogle Scholar
  17. 17.
    Canetti-Nisim D et al (2009) A new stress-based model of political extremism: personal exposure to terrorism, psychological distress, and exclusionist political attitudes. J Confl Resolut 53(2):363–389CrossRefGoogle Scholar
  18. 18.
    Turecki G, Brent DA (2016) Suicide and suicidal behaviour. Lancet 387(10024):1227–1239CrossRefPubMedGoogle Scholar
  19. 19.
    Spallek J et al (2015) Suicide among immigrants in Europe—a systematic literature review. Eur J Public Health 25(1):63–71CrossRefPubMedGoogle Scholar
  20. 20.
    RCore Team R (2014) A language and environment for statistical computing. R Core Team R, ViennaGoogle Scholar
  21. 21.
    Li Z et al (2011) Attributable risk of psychiatric and socio-economic factors for suicide from individual-level, population-based studies: a systematic review. Soc Sci Med 72(4):608–616CrossRefPubMedGoogle Scholar
  22. 22.
    Rehkopf DH, Buka SL (2006) The association between suicide and the socio-economic characteristics of geographical areas: a systematic review. Psychol Med 36(2):145–157CrossRefPubMedGoogle Scholar
  23. 23.
    Knipe DW et al (2015) Association of socio-economic position and suicide/attempted suicide in low and middle income countries in South and South-East Asia—a systematic review. BMC Public Health 15:1055CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Therneau TM (2000) Modeling survival data: extending the Cox model. Springer, New YorkCrossRefGoogle Scholar
  25. 25.
    Nakash O et al (2013) The effect of cancer on suicide among elderly Holocaust survivors. Suicide Life Threat Behav 43(3):290–295CrossRefPubMedGoogle Scholar
  26. 26.
    Sagi-Schwartz A et al (2013) Against all odds: genocidal trauma is associated with longer life-expectancy of the survivors. PLoS One 8(7):e69179CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Barel E et al (2010) Surviving the Holocaust: a meta-analysis of the long-term sequelae of a genocide. Psychol Bull 136(5):677–698CrossRefPubMedGoogle Scholar
  28. 28.
    Levine SZ et al (2016) Exposure to genocide and the risk of schizophrenia: a population-based study. Psychol Med 46(4):855–863CrossRefPubMedGoogle Scholar
  29. 29.
    Antonovsky A et al (1971) Twenty-five years later: a limited study of the sequelae of the concentration camp experience. Soc Psychiatry 6(4):186–193CrossRefGoogle Scholar
  30. 30.
    Hantman S, Solomon Z (2007) Recurrent trauma: Holocaust survivors cope with aging and cancer. Soc Psychiatry Psychiatr Epidemiol 42(5):396–402CrossRefPubMedGoogle Scholar
  31. 31.
    Shuval JT (1957) Some persistent effects of trauma: five years after the Nazi concentration camps. Soc Probl 5(3):230–243CrossRefGoogle Scholar
  32. 32.
    Robinson S et al (1994) Retraumatization of Holocaust survivors during the Gulf War and SCUD missile attacks on Israel. Br J Med Psychol 67(Pt 4):353–362CrossRefPubMedGoogle Scholar
  33. 33.
    Collins C et al (2004) Health status and mortality in Holocaust survivors living in Jerusalem 40–50 years later. J Trauma Stress 17(5):403–411CrossRefPubMedGoogle Scholar
  34. 34.
    Torrey EF, Yolken RH (2010) Psychiatric genocide: nazi attempts to eradicate schizophrenia. Schizophr Bull 36(1):26–32CrossRefPubMedGoogle Scholar
  35. 35.
    Lavi I, Bar-Tal D (2015) In: Lindert J, Levav I (eds) Violence in prolonged conflicts and its socio-psychological effects in violence and mental health: its manifold faces. Springer, The Netherlands, pp 3–26Google Scholar
  36. 36.
    Finklestein M, Solomon Z (2009) Cumulative trauma, PTSD and dissociation among Ethiopian refugees in Israel. J Trauma Dissoc 10(1):38–56CrossRefGoogle Scholar
  37. 37.
    Sagi A et al (2002) Disorganized reasoning in Holocaust survivors. Am J Orthopsychiatry 72(2):194–203CrossRefPubMedGoogle Scholar
  38. 38.
    Sagi-Schwartz A et al (2003) Attachment and traumatic stress in female Holocaust child survivors and their daughters. Am J Psychiatry 160(6):1086–1092CrossRefPubMedGoogle Scholar
  39. 39.
    Rostila M, Saarela J, Kawachi I (2012) Mortality in parents following the death of a child: a nationwide follow-up study from Sweden. J Epidemiol Community Health 66(10):927–933CrossRefPubMedGoogle Scholar
  40. 40.
    Taylor PJ et al (2011) The role of defeat and entrapment in depression, anxiety, and suicide. Psychol Bull 137(3):391–420CrossRefPubMedGoogle Scholar
  41. 41.
    Froom P et al (2004) Predicting self-reported health: the CORDIS study. Prev Med 39(2):419–423CrossRefPubMedGoogle Scholar
  42. 42.
    Bakst SS et al (2016) The accuracy of suicide statistics: are true suicide deaths misclassified? Soc Psychiatry Psychiatr Epidemiol 51(1):115–123CrossRefPubMedGoogle Scholar
  43. 43.
    Levav I, Greenfeld H, Baruch E (1979) Psychiatric combat reactions during the Yom Kippur War. Am J Psychiatry 136(5):637–641CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2016

Authors and Affiliations

  • Cendrine Bursztein Lipsicas
    • 1
  • Itzhak Levav
    • 1
  • Stephen Z. Levine
    • 1
  1. 1.Department of Community Mental Health, Faculty of Social Welfare and Health SciencesUniversity of HaifaHaifaIsrael

Personalised recommendations