title: Holocaust exposure and subsequent suicide risk: a population-based study.
abstract: 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.
authors.affiliation: Department of Community Mental Health, Faculty of Social Welfare and Health Sciences, University of Haifa, 3498838, Haifa, Israel. cendrinebursztein@gmail.com.
authors.forename: Cendrine
authors.initials: C
authors.lastname: Bursztein Lipsicas
authors.affiliation: Department of Community Mental Health, Faculty of Social Welfare and Health Sciences, University of Haifa, 3498838, Haifa, Israel.
authors.forename: Itzhak
authors.initials: I
authors.lastname: Levav
authors.affiliation: Department of Community Mental Health, Faculty of Social Welfare and Health Sciences, University of Haifa, 3498838, Haifa, Israel.
authors.forename: Stephen Z
authors.initials: SZ
authors.lastname: Levine
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D017767:Holocaust / Q000706:statistics & numerical data*; D006801:Humans; D007557:Israel / Q000453:epidemiology; D008297:Male; D012042:Registries / Q000706:statistics & numerical data*; D013405:Suicide / Q000706:statistics & numerical data*; D017741:Survivors / Q000706:statistics & numerical data*
keywords: Epidemiology; Genocide; Holocaust; Suicide