Holocaust exposure and subsequent suicide risk: a population-based study
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To examine the association between the extent of genocide exposure and subsequent suicide risk among Holocaust survivors.
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.
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.
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.
KeywordsSuicide Genocide Holocaust Epidemiology
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
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.
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