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Rocky Mountain MIRECC for Veteran Suicide Prevention

Rocky Mountain MIRECC for Veteran Suicide Prevention

Updated: 1 November 2018


Peter M. GutierrezDr. Peter M. Gutierrez
Title: Clinical/Research Psychologist
303.329.4408 ext. 301
Fellowship Training Faculty
Clinical Interest: Cognitive-Behavioral Therapy for Major Depression and high suicide risk
Year of Licensure: 2008
Peter M. Gutierrez, Ph.D. is a licensed Clinical Psychologist at the VA VISN 19 MIRECC. Dr. Gutierrez's clinical training was in child and adolescent psychology, with an emphasis on serious psychopathology and suicide. He is Professor of Psychiatry at the University of Colorado School of Medicine. He has been studying suicide, focusing on screening, assessment, and intervention for over 20 years. Dr. Gutierrez is a Past-President of the American Association of Suicidology (AAS). He was the 2005 recipient of the AAS Shneidman Award for outstanding contributions in research in suicidology and the 2014 recipient of the Roger J. Tierney Award for Service. He is an Associate Editor for the journal Suicide and Life-Threatening Behavior, a consulting editor for Archives of Suicide Research, and regularly reviews for other psychology, psychiatry, and specialty journals. Dr. Gutierrez is a member of the MIRECC psychology fellowship training committee, provides supervision and mentoring for psychology pre-doctoral interns, and MIRECC psychology fellows. He has provided numerous VA trainings and conference presentations on issues related to clinical care of Veterans at high risk of suicide, the interplay of TBI, PTSD and suicide, and related topics. Dr. Gutierrez is co-Director, with Dr. Thomas Joiner at Florida State University, of the DOD funded Military Suicide Research Consortium. He and Dr. Joiner are joint recipients of the 2018 Military Health System Research Symposium (MHSRS) Outstanding Research Accomplishment (Team/Academia) Award and the American Psychological Association (APA) Division 19 Society of Military Psychology’s 2018 Charles C. Gersoni Military Psychology Award. He is also a co-I on a DOD funded long-term follow-up study of Veterans who participated in a suicide-specific group therapy study. In terms of unfunded research, Dr. Gutierrez is PI or co-PI on a range of studies with MIRECC and outside collaborators on topics related to multiple aspects of Veteran and military suicidality.
Statement about research program: Dr. Gutierrez is a downstream suicide prevention researcher focusing on suicide-specific clinical interventions and assessment approaches. Within his assessment line of research, he seeks to refine suicide assessment approaches to enable clinicians to make predictions about acute suicide risk so that treatment planning can be optimized for the greatest potential to prevent subsequent suicide-related behaviors. He believes the most promising work will focus on identification of near-term risk (i.e., warning signs). To be most useful, tools need to be validated in a range of clinical settings from Emergency Departments to Inpatient Psychiatric to Outpatient Mental and Behavioral Health. Within his clinical interventions line of research, he believes that suicide is a clinical problem requiring targeted interventions to reduce the probability of individual patients transitioning from thoughts of suicide to action (i.e., attempts and suicide). The most effective interventions will likely be those targeting factors which facilitate those transitions. To have broad uptake, interventions need to be simple enough that providers from multiple disciplines can learn to deliver them effectively and with fidelity. Interventions should also be available in individual and group format to increase the range of clinical settings in which they can be delivered in a cost-effective manner. Most suicide-specific interventions are currently psychosocial in nature and delivered face-to-face by a single clinician or co-facilitator team. Other modes of delivery, such as web-based, telehealth, and mobile applications also hold promise. Determining the optimal dose of intervention, as a function of type and delivery method is also essential to successful suicide prevention. Finally, interventions not strictly psychosocial in nature hold promise as an element of overall efforts to reduce suicide morbidity and mortality.
Clinical Interests: Dr. Gutierrez is a cognitive-behavioral therapist with extensive experience providing care for veterans at high risk of suicide. He is particularly interested in how veterans’ combat experiences contribute to their risk of suicidality, often through symptoms of PTSD and sleep disturbance. Additionally, Dr. Gutierrez’s clinical work is strongly influenced by Dr. Jobes’ Collaborative Assessment and Management of Suicide (CAMS) approach. He is also heavily involved with public health approaches to suicide prevention through work with the Colorado Department of Public Health and Environment’s Office of Suicide Prevention.

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RMIRECC Short Takes Podcast - Response to "Is it time to abandon suicide risk assessment"

16 March 2016

Welcome to our third RM Short Takes podcast. This week Adam Hoffberg interviews Dr. Peter Gutierrez about an editorial by Dr Declan Murray in the British Journal of Psychiatry Open (DOI: 10.1192/bjpo.bp.115.002071) in which Dr Murray discusses abandoning suicide risk assessment. As you might expect, the answer is not a simple yes or no.

The podcast is approximately 14 minutes long.

You can subscribe to the RM Short Takes Podcast on iTunes or your favorite podcasts tool.

Categories: Suicide Prevention; Clinicians; Suicide Risk Assessment

RMIRECC Short Takes Podcast - Risk Factors, Warning Signs, and Drivers of Suicide

10 February 2016

Listen to our first podcast with Adam Hoffberg interviewing Dr. Peter Gutierrez regarding his latest publication "Risk Factors, Warning Signs, and Drivers of Suicide: What Are They, How Do They Differ, and Why Does It Matter?" in Suicide and Life-Threatening Behavior.


The podcast is approximately 26 minutes long.

Categories: Suicide Prevention; Clinicians

Youth Suicide Warning Signs video:
Peter Gutierrez, PhD describes work creating a consensus Youth Suicide Warning Signs. Learn more at:

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Recent Publications

A Randomized Controlled Trial of the Collaborative Assessment and Management of Suicidality versus Enhanced Care as Usual With Suicidal Soldiers
27 February 2018 - Drs. Brenner and Gutierrez participated in this randomized controlled trial known as "Operation Worth Living" (OWL). The study sought to compare the treatment use of Collaborative Assessment and Management of Suicidality (CAMS) to enhanced care as usual (E-CAU) in the reduction of both suicidal ideation and suicide attempts in US Army Soldiers. From the abstract, "Conclusions: Soldiers receiving CAMS and E-CAU significantly improved post-treatment. Those who received CAMS were less likely to report SI at 3 months; further group differences were not otherwise seen." Read more.
Evaluation of Structured Assessment and Mediating Factors of Suicide-Focused Group Therapy for Veterans Recently Discharged from Inpatient Psychiatry
26 February 2018 - Dr. Peter Gutierrez teamed up with six co-authors on this publication which explored whether adding the Suicide Status Form (SSF) to a suicide-focused group therapy for veterans showed benefit. An added note here both Pete and David Jobes have recorded podcasts with us! Catch Pete's podcast "Risk Factors, Warning Signs, and Drivers of Suicide: What Are They, How Do They Differ, and Why Does It Matter?" and David Jobes' podcast "Looking 30 Years Ahead and 30 Years Behind with David A. Jobes".
Nock, M. K., Millner, A. J., Joiner, T. E., Gutierrez, P. M., Han, G., Hwang, I….& Kessler, R. C. (in press). Risk Factors for the Transition from Suicide Ideation to Suicide Attempt: Results from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). Journal of Abnormal Psychology.
Jobes, D. A., Comtois, K. A., Gutierrez, P. M., Brenner, L.A., Huh, D., Chalker, S. A….& Crow, B. (in press). A Randomized Controlled Trial of the Collaborative Assessment and Management of Suicidality versus Enhanced Care as Usual with Suicidal Soldiers. Psychiatry: Interpersonal and Biological Processes.
Ringer, F., Soberay, K., Rogers, M., Hagan, C., Chu, C., Schneider, M., Podlogar, M., Witte, T., Holm-Denoma, J., Plant, A., Guiterrez, P., & Joiner, T., (in press). Initial validation of brief measures of suicide risk factors: Common Data Elements used by the Military Suicide Research Consortium. Psychological Assessment.
Gutierrez, P. M., Wortzel, H. S., Forster, J. E., Leitner, R. A., Hostetter, T. A., & Brenner, L. A. (in press). Blister packaging medication increases treatment adherence for psychiatric patients. Journal of Psychiatric Practice.
Ribeiro, J. D., Gutierrez, P. M., Joiner, T. E., Kessler, R. C., Petukhova, M. V., Sampson, N. A., Stein, M. B., Ursano, R. J., & Nock (2017). Healthcare Contact and Suicide Risk Documentation prior to Suicide Death: Results from the Army Study to Assess Risk. Journal of Consulting and Clinical Psychology, 85(4), 403-408. doi: 10.1037/ccp0000178
OBJECTIVE: Prior research has shown that a substantial portion of suicide decedents access health care in the weeks and months before their death. We examined whether this is true among soldiers. METHOD: The sample included the 569 Regular Army soldiers in the U.S. Army who died by suicide on active duty between 2004 and 2009 compared to 5,690 matched controls. Analyses examined the prevalence and frequency of health care contacts and documentation of suicide risk (i.e., the presence of prior suicidal thoughts and behaviors) over the year preceding suicide death. Predictors of health care contact and suicide risk documentation were also examined. RESULTS: Approximately 50% of suicide decedents accessed health care in the month prior to their death, and over 25% of suicide decedents accessed health care in the week prior to their death. Mental health encounters were significantly more prevalent among suicide decedents (4 weeks: 27.9% vs. 7.9%, χ2 = 96.2, p < .001; 52 weeks: 59.4% vs. 33.7%, χ2 = 120.2, p < .001). Despite this, risk documentation was rare among suicide decedents (4 weeks: 13.8%; 52 weeks: 24.5%). Suicide decedents who were male, never married, and non-Hispanic Black were less likely to access care prior to death. Number of mental health encounters was the only predictor of suicide risk documentation among decedents at 4 weeks (OR = 1.14) and 52 weeks (OR = 1.05) prior to their death. CONCLUSIONS: Many soldiers who die by suicide access health care shortly before death, presenting an opportunity for suicide prevention. However, in most cases, there was no documentation of prior suicidal thoughts or behaviors, highlighting the need for improvements in risk detection and prediction. Increasing the frequency, scope, and accuracy of risk assessments, especially in mental health care settings, may be particularly useful. (PsycINFO Database Record © 2017 APA, all rights reserved).
Hom, M. A., Chu, C., Schneider, M. E., Lim, I. C., Hirsch, J. K., Gutierrez, P. M., & Joiner, T. E. (2017). Thwarted belongingness as an explanatory link between insomnia and suicidal ideation: Findings from three samples of military service members and veterans. Journal of Affective Disorders, 209, 114-123. doi: 10.1016/j.jad.2016.11.032
Background: Although insomnia has been identified as a robust predictor of suicidal ideation and behaviors, little is known about the mechanisms by which sleep disturbances confer risk for suicide. We investigated thwarted belongingness as an explanatory link between insomnia symptoms and suicidal ideation across three military service member and veteran samples. Methods: Data were collected among United States military service members and veterans (N1=937, N2=3,386, N3=417) who completed self-report measures of insomnia symptoms, thwarted belongingness, suicidal ideation, and related psychiatric symptoms (e.g., anxiety, hopelessness). Bias-corrected bootstrap mediation analyses were utilized to examine the indirect effects of insomnia symptoms on suicidal ideation through thwarted belongingness, controlling for related psychiatric symptoms. Results: Consistent with study hypotheses, thwarted belongingness significantly accounted for the relationship between insomnia and suicidal ideation across all three samples; however, insomnia symptoms did not significantly account for the relationship between thwarted belongingness and suicidal ideation, highlighting the specificity of our findings. Limitations: This study utilized cross-sectional self-report data. Conclusions: Insomnia may confer suicide risk for military service members and veterans, in part, through the pathway of thwarted belongingness. Additional prospective studies are warranted to further delineate this model of risk. Our results offer a potential therapeutic target for the prevention of suicide, via the promotion of belongingness, among service members and veterans experiencing insomnia symptoms. Keywords: Insomnia, Suicidal ideation, Loneliness, Thwarted belongingness, Military, Veterans
O'Connor, S.S., Carney, E., Jennings, K.W., Johnson, L. L., Gutierrez, P. M., & Jobes, D. A. (2016). Relative Impact of Risk Factors, Thwarted Belongingness, and Perceived Burdensomeness on Suicidal Ideation in Veteran Service Members. Journal of Clinical Psychology, 00(0), 1-10. doi:10.1002/jclp.22426
Objective: We tested the associations between individualized risk factors, empirically validated constructs specific to suicide risk (i.e., thwarted belongingness and perceived burdensomeness, and two methods for conceptualizing suicidal ideation based on Suicide Index Score (SIS) and overall severity score of the Beck Scale for Suicide Ideation [BSS]). Method: The current study included a sample of 134 suicidal Veterans who were recruited from an inpatient psychiatry unit of a Veterans Affairs Medical Center. Participants completed the BSS, Interpersonal Needs Questionnaire, Outcome Questionnaire-45.2, Alcohol Use Disorder Identification Test, Drug Abuse Screening Test, and abbreviated versions of the Posttraumatic Stress Disorder Checklist-Military version (PCL-M) and Insomnia Severity Index. We used ordinary least squares regression with bootstrapping to conduct analyses due to the skewed distributions observed in the suicidal ideation outcomes. Results: Thwarted belongingness was the only statistically significant correlate of the SIS, indicating a stronger desire to be dead than alive as Veterans perceived themselves as being increasingly disconnected and isolated from others (B = 0.36, standard error [SE] = 0.01, p = 0.005). In contrast, greater overall severity scores on the BSS were associated with higher ratings on the PCL-M (B = 0.21, SE = 0.07, p = 0.02) and for thwarted belongingness (B = 0.27, SE = 0.09, p = 0.04). Problematic alcohol use was significantly associated with lower overall severity scores (B = −.27, SE = 1.17, p < 0.001). Conclusion: Findings may inform clinical strategies for conceptualizing and targeting factors associated with suicidal risk.
Hom, M. A., Stanley, I. H., Gutierrez, P. M., & Joiner, T. E. (2016). Exploring the association between exposure to suicide and suicide risk among military service members and veterans. Journal of Affective Disorders. doi:10.1016/j.jad.2016.09.043
Background: Past research suggests that suicide has a profound impact on surviving family members and friends; yet, little is known about experiences with suicide bereavement among military populations. This study aimed to characterize experiences with suicide exposure and their associations with lifetime and current psychiatric symptoms among military service members and veterans. Methods: A sample of 1,753 United States military service members and veterans completed self-report questionnaires assessing experiences with suicide exposure, lifetime history of suicidal thoughts and behaviors, current suicidal symptoms, and perceived likelihood of making a future suicide attempt. Results: The majority of participants (57.3%) reported knowing someone who had died by suicide, and of these individuals, most (53.1%) reported having lost a friend to suicide. Chi-square tests, one-way ANOVAs, and logistic regression analyses revealed that those who reported knowing a suicide decedent were more likely to report more severe current suicidal symptoms and a history of suicidal thoughts and behaviors compared to those who did not know a suicide decedent. Hierarchical linear regression analyses indicated that greater self-reported interpersonal closeness to a suicide decedent predicted greater self-reported likelihood of a future suicide attempt, even after controlling for current suicidal symptoms and prior suicidal thoughts and behaviors. Limitations: This study utilized cross-sectional data, and information regarding degree of exposure to suicide was not collected. Conclusions: Military personnel and veterans who have been bereaved by suicide may themselves be at elevated risk for suicidal thoughts and behaviors. Additional work is needed to delineate the relationship between these experiences. Keywords: Suicide; Bereavement; Survivor; Military service member; Veteran.
Gutierrez, P. M., Pease, J., Matarazzo, B. B., Monteith, L. L., Hernandez, T., & Osman, A. (2016). Evaluating the psychometric properties of the Interpersonal Needs Questionnaire and the Acquired Capability for Suicide Scale in military veterans. Psychological Assessment.
Joiner's (2005) interpersonal-psychological theory of suicide (IPTS) has become one of the most frequently studied in the field. Currently there are 2 primary measures designed to assess the 3 main constructs of the theory-the Interpersonal Needs Questionnaire (INQ; Van Orden, Witte, Gordon, Bender, & Joiner, 2008) and the Acquired Capability for Suicide Scale (ACSS; Van Orden et al., 2008). The psychometric properties of these 2 measures were evaluated in a sample of 477 U.S. military veterans. It was determined that the factor structure for both measures is consistent with the underlying theory and that all internal consistency reliability estimates are good. Acceptable convergent validity was found for the INQ, but not for the ACSS. Recommendations for refining the ACSS based on the results of the current analyses are provided. Comparisons of scale performance were made with data from participants with and without a history of 1 or more suicide attempts. Burdensomeness alone and the interaction between thwarted belongingness and burdensomeness were associated with prior suicide attempts. In conclusion, although some refinement may improve performance of the ACSS, both measures are appropriate and psychometrically sound for use in research and clinical applications with veterans of the U.S. military. (PsycINFO Database Record (c) 2016 APA, all rights reserved).
Joiner TE, Hom MA, Rogers ML, Chu C, Stanley IH, Wynn GH, Gutierrez PM. Staring Down Death. Crisis. 2016 May;37(3):212-7. doi: 10.1027/0227-5910/a000367. Epub 2016 Jan 19. PubMed PMID: 27427541.
BACKGROUND: Lowered eye blink rate may be a clinically useful indicator of acute, imminent, and severe suicide risk. Diminished eye blink rates are often seen among individuals engaged in heightened concentration on a specific task that requires careful planning and attention. Indeed, overcoming one's biological instinct for survival through suicide necessitates premeditation and concentration; thus, a diminished eye blink rate may signal imminent suicidality. AIMS: This article aims to spur research and clinical inquiry into the role of eye blinks as an indicator of acute suicide risk. METHOD: Literature relevant to the potential connection between eye blink rate and suicidality was reviewed and synthesized. RESULTS: Anecdotal, cognitive, neurological, and conceptual support for the relationship between decreased blink rate and suicide risk is outlined. CONCLUSION: Given that eye blinks are a highly observable behavior, the potential clinical utility of using eye blink rate as a marker of suicide risk is immense. Research is warranted to explore the association between eye blink rate and acute suicide risk. KEYWORDS: blink rate; eye blink; suicide
Davidson CL, Anestis MD, Gutierrez PM. Ecological Momentary Assessment is a Neglected Methodology in Suicidology. Arch Suicide Res. 2016 Jan 29:1-11. [Epub ahead of print] DOI: 10.1080/13811118.2015.1004482 PubMed PMID: 26821811.
Ecological momentary assessment (EMA) is a group of research methods that collect data frequently, in many contexts, and in real-world settings. EMA has been fairly neglected in suicidology. The current article provides an overview of EMA for suicidologists including definitions, data collection considerations, and different sampling strategies. Next, the benefits of EMA in suicidology (i.e., reduced recall bias, accurate tracking of fluctuating variables, testing assumptions of theories, use in interventions), participant safety considerations, and examples of published research that investigate self-directed violence variables using EMA are discussed. The article concludes with a summary and suggested directions for EMA research in suicidology with the particular aim to spur the increased use of this methodology among suicidologists. KEYWORDS: Ecological Momentary Assessment; Experience Sampling Method; suicide
Gutierrez, P. M., Davidson, C., Friese, A., & Forster, J. (2016). Physical activity, suicide risk factors, and suicidal ideation in a veteran sample. Suicide and Life-Threatening Behavior, 46(3), 284-292. doi: 10.1111/sltb.12190
The association between current level of suicidal ideation and physical activity was tested in a broad sample of veterans seeking care from the Veterans Health Administration. It was hypothesized that the two variables would be significantly inversely related. It was further hypothesized that the relationship would be mediated by depressive symptoms, disturbed sleep, and a measure of heart rate variability based on existing research regarding physical activity and sleep. Due to the first hypothesis not being supported, the second could not be tested. Post hoc correlation analyses did find associations between physical activity and depressive symptoms, in expected directions, and are discussed. Possible explanations for the negative findings along with recommendations for future research to continue exploring links between suicide risk and physical activity are presented. We conclude by suggesting that physical activity may have promise as a risk reduction intervention and that prospective data are more likely to yield significant results than the cross-sectional methodology employed in the current study. © Published 2015. This article is a U.S. Government work and is in the public domain in the USA.

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