The Role of Nurse Practitioners in the Reframing of Suicide Risk

Abstract

Objectives:

Suicide remains a significant public health challenge in the United States and globally, with risk influenced not only by mental health conditions but also by social and structural factors. This analysis examines how social determinants of health contribute to suicide risk and identifies evidence-supported nurse practitioner (NP) interventions that may reduce vulnerability in primary care settings.

Methods:

A theory-based analysis was conducted using the World Health Organization Social Determinants of Health framework, the Stress Process Model, and Joiner’s Interpersonal Theory of Suicide to examine how social conditions influence suicide risk and to identify opportunities for NP intervention.

Results:

Economic hardship contributes to chronic stress and perceived burdensomeness, social isolation weakens protective belongingness, and limited access to behavioral health services delays treatment of depression and suicidal ideation. Evidence supports NP-led strategies, including social determinants screening, collaborative care models, integrated behavioral health services, and structured suicide risk assessment protocols as practical approaches to addressing these risks.

Conclusion:

Effective suicide prevention requires expanding beyond symptom management to include upstream social risk factors. Nurse practitioners are well-positioned to lead these efforts through early identification, integrated care delivery, and whole-person primary care models addressing both clinical and social drivers of suicide risk.

Introduction

Suicide remains a major public health concern worldwide, with more than 720 000 deaths annually and ranking among the leading causes of death for adolescents and young adults. ¹ In the United States, nearly 49 000 individuals died by suicide in 2023. ² Primary care settings represent one of the most important yet underutilized opportunities for suicide prevention.^3,4

Research indicates that most individuals who die by suicide have had healthcare contact within the year before death, frequently within primary care rather than behavioral health settings. This places nurse practitioners, who often serve as first points of contact, in a critical position to identify risk and intervene early. Financial strain and material insecurity contribute to chronic stress and hopelessness, while social isolation erodes protective support; early work linked isolation to increased morbidity and mortality, underscoring its relevance to suicide risk. ⁵ Barriers to timely care further delay identification and intervention, and these factors frequently co-occur, amplifying risk beyond symptom-focused approaches. This manuscript examines these determinants and proposes a theory-based framework with actionable implications for nurse practitioner (NP) led prevention in primary care.

Methods

This manuscript employs a theory-based analysis to examine suicide risk as an outcome shaped by social and structural determinants and to inform NP-led prevention strategies in primary care. Targeted searches of PubMed, CINAHL, PsycINFO, and Google Scholar identified peer-reviewed literature on suicide risk, economic hardship, social isolation and loneliness, access to mental health care, and primary care prevention, prioritizing population-based studies, systematic reviews, and foundational theoretical works published primarily between 2015 and 2025. Evidence synthesis was guided by the World Health Organization’s Social Determinants of Health framework, Pearlin’s Stress Process Model, and Joiner’s Interpersonal Theory of Suicide to support development of an integrated, practice-relevant conceptual model. Core constructs were extracted from these complementary theories, an overlap map was completed, and these elements were integrated into the practice-relevant conceptual model linking structural determinants to proximal suicide risk.

Review of Literature and Description of Concepts

Suicide

Suicide is the intentional act of ending one’s own life and is associated with interacting factors, including psychiatric and medical conditions, socioeconomic status, loneliness, and limited access to care.^6,7 Reduced access to mental health services is linked to increased suicide risk, particularly during care transitions.^3,8 In a nationally representative U.S. sample, suicidal ideation was more prevalent among individuals experiencing economic pressure and loneliness. ⁹ Population-based studies further indicate elevated risk of suicide attempts and death before care initiation and following discharge from psychiatric hospitalization.^10,11 Despite this evidence, gaps remain in understanding how social determinants of health and economic factors shape suicide risk.

Economic Hardship

Economic hardship reflects insufficient resources to meet basic financial needs and operates at both individual and population levels. ¹² At the individual level, it includes debt, unemployment, under-employment, and job insecurity, while at the population level, it encompasses broader economic conditions such as unemployment rates, recession, inflation, and gross domestic product.^12-14 Both personal financial strain and national economic downturns are key determinants of suicide risk. ¹⁵

Reviews and population-based analyses consistently identify economic hardship as a critical determinant of suicidal behavior and suggest that policy-level interventions mitigating financial distress during economic instability may reduce risk.^12,16 Empirical evidence links financial indebtedness to a 2.5-fold increased risk of suicide death, ¹⁷ food insecurity to suicide and other forms of violence, ¹⁸ and financial stress (74%) and unemployment (87%) to elevated suicide risk across 20 nations. ¹⁹ At the individual level, debt, unemployment, prior homelessness, and reduced income independently predict suicidal ideation and attempts, with individuals endorsing all factors demonstrating a 20-fold higher predicted probability of suicide. ²⁰

While direct evidence linking PRAPARE screening and social service referral to reduced suicide mortality is limited, these interventions are supported as upstream prevention strategies because they address financial stress, depression, and barriers to care that are well-established contributors to suicide risk. Nurse practitioners can address these upstream risks through structured screening for social determinants and referral coordination. Tools such as PRAPARE help identify unmet needs, and evidence suggests screening combined with referral navigation improves resource connection and reduces psychological distress. ²¹

Social Isolation and Loneliness

Social isolation reflects the absence of social engagement and relationships, whereas loneliness denotes a subjective sense of perceived isolation.^4,22,23 Both are recognized as priority suicide risk factors and are positively associated with suicide, with available evidence linking social isolation to suicide risk despite more limited studies.^24-28 Short-term increases in suicidal desire are associated with fluctuations in interpersonal hopelessness, highlighting the dynamic nature of risk among socially disconnected individuals. ²⁹ The relationship between loneliness and suicidal behavior is shaped by individual, social, and cultural factors, including economic hardship, mental health disorders, and substance use. ³⁰ Loneliness shows a distinct lifespan pattern, with the highest prevalence in adolescence and older adulthood, paralleling age-related patterns of suicidal behavior across populations.^31-33 Consistent with these patterns, elevated suicidal ideation has been documented among socially marginalized adolescents and older adults, and loneliness has been identified as a predictor of suicidal ideation and behavior, with depression acting as a mediator, particularly among individuals aged 16 to 20 years and those over 58 years.^3,34

Limited Mental Health Care

Timely access to mental health care is essential to suicide prevention, yet nearly half of individuals who attempt suicide report being unable to access treatment beforehand, and limited provider availability is associated with increased suicide risk.^8,35 Suicide risk is highest before treatment initiation and during transitions from inpatient to community care, reflecting critical gaps in continuity.^3,8,10,11 Collaborative care addresses these gaps by integrating mental health services into primary care, improving access and continuity, and reducing suicidal ideation.^36-38 Barriers and facilitators to early engagement in primary-care-based mental health services have been identified, offering actionable strategies to improve access for patients at risk for suicide. ⁴

Conceptual Framework

The proposed conceptual model integrates the World Health Organization’s Social Determinants of Health (SDH) framework, Pearlin and colleagues’ Stress Process Model (SPM), and Joiner’s Interpersonal Theory of Suicide (ITS) to show that suicide results from the interaction of individual factors with broader social systems, such as poverty, racism, housing instability, and limited access to care, that create and perpetuate unequal risk, rather than arising solely from individual psychology (Figure 1). Although each framework has been applied independently, their integration clarifies how social and economic conditions translate into chronic stress, interpersonal vulnerability, and suicide risk within healthcare contexts.

Figure 1.

Integrated conceptual model of suicide risk as a systemic outcome.

This model links upstream structural determinants, including economic hardship, social isolation, and limited access to mental health care, to suicide risk through chronic stress processes and interpersonal mechanisms of thwarted belongingness, perceived burdensomeness, and hopelessness. Grounded in the SDH framework, ³⁹ the Stress Process Model, ⁴⁰ and the Interpersonal Theory of Suicide, ⁴¹ highlights primary care as a critical intervention point for NP-led prevention. The SDH framework emphasizes unequal exposure to social and economic conditions, the Stress Process Model explains how chronic stressors accumulate in the context of limited coping resources to produce adverse mental health outcomes,^40,42 and the Interpersonal Theory of Suicide identifies thwarted belongingness and perceived burdensomeness as central drivers of suicidal desire, supported by extensive empirical evidence.^43-45 Within this framework, economic hardship may intensify perceived burdensomeness, social isolation contributes to thwarted belongingness, and limited access to care delays identification and intervention, allowing risk to escalate. By explicitly linking structural determinants to interpersonal mechanisms and clinical intervention points, the model reframes suicide prevention as a system-level responsibility and positions primary care strategies, including universal screening, collaborative care, and co-located behavioral health services, as downstream interventions capable of interrupting upstream inequities and supporting NP-led suicide prevention.

Model Case Exemplar: Key Strategies for Integration

The model identifies economic hardship, social isolation, and limited access to mental health care as upstream determinants that activate stress and interpersonal risk mechanisms for suicidality. Primary care, where NPs are often the first or only point of contact, is therefore a critical intervention site, particularly given that about half of suicide decedents had recent primary care contact, while fewer than half of those with suicidal ideation access mental health services due to stigma, cost, isolation, and access barriers. ³⁵ Routine use of validated tools such as the PHQ-9, GAD-7, and PRAPARE enables early identification of psychological distress and upstream social stressors. Collaborative care, co-located behavioral health services, and warm handoffs reduce treatment delays and access barriers, while standardized suicide risk protocols operationalize responses to thwarted belongingness, perceived burdensomeness, and hopelessness. Culturally responsive approaches further strengthen trust, engagement, and protective social connection among populations disproportionately affected by structural disadvantages.

Integrated Synthesis and Contribution to Literature

This synthesis advances suicide prevention by presenting an integrated, systems-oriented framework showing how economic hardship, social isolation, and limited access to mental health care interact as reinforcing structural pathways that elevate suicide risk through chronic stress and interpersonal mechanisms. Economic hardship generates sustained stress and perceived burdensomeness, social isolation and loneliness undermine support and belonging, and constrained access to care delays identification and disrupts continuity, particularly during care transitions. By linking social determinants, stress processes, and interpersonal mechanisms to actionable intervention points, the model positions primary care and NP-led strategies as central to equitable, system-level suicide prevention embedded in routine practice rather than reactive crisis response.

Implications for Nurse Practitioner Professionals

The proposed model advances suicide prevention by integrating social determinants of health, interpersonal theory, and stress process perspectives into a systems-oriented framework centered in NP primary care. By synthesizing economic hardship, social isolation, and access to mental health care, it shows how structural inequities translate into interpersonal vulnerability and clinical risk and links upstream social conditions to actionable intervention points. Centering NPs as operational leaders, the model addresses a gap in the literature on NP roles in system-level suicide prevention and supports equitable, scalable strategies beyond individual pathology, with Table 1 operationalizing these links through NP-led interventions in primary care. To strengthen the clinical relevance of these recommendations, Table 1 summarizes not only suicide risk associations but also available evidence supporting NP interventions aimed at mitigating these risks.

Table 1.

Social Determinants of Suicide Risk and NP Intervention Strategies.

Model component/determinant	Impact on suicide risk	NP intervention strategies
Economic hardship	Financial strain increases depression, chronic stress, and hopelessness, which are associated with suicide risk.	Screen using PRAPARE or other SDOH tools; refer to housing, food, and employment resources; implement closed-loop referrals; screen for depression when financial stress is identified.
Social isolation and loneliness	Associated with depression, suicidal ideation, and reduced protective social support.	Screen for loneliness; refer to community programs, social prescribing, behavioral health referral, and proactive follow-up.
Limited access to behavioral health care	Untreated depression and anxiety significantly increase suicide risk.	Implement collaborative care model; co-located behavioral health; warm handoffs; routine PHQ-9 screening; suicide risk assessment.
Barriers to healthcare access	Delayed treatment may worsen mental health conditions associated with suicide risk.	Improve care coordination; use telehealth; reduce follow-up gaps; care navigation.
Fragmented care systems	Poor continuity may lead to missed suicide warning signs.	Measurement-based care; registry tracking; proactive outreach to high-risk patients.

While direct evidence linking social determinant interventions to suicide mortality reduction remains limited, substantial evidence supports NP interventions that reduce depression severity, improve treatment engagement, and address upstream psychosocial stressors known to increase suicide risk. These strategies reflect a population health approach to suicide prevention by targeting modifiable clinical and social risk factors.

Conclusion

Suicide remains a critical public health challenge shaped by social and structural contexts as well as individual mental health conditions, and it continues to rank among the leading causes of death globally. ¹ Economic hardship, social isolation, and limited access to mental health care intersect to heighten risk and constrain early intervention, requiring prevention strategies that extend beyond symptom management to address systemic inequities. Integrating mental health services into primary care, through universal screening, collaborative care, co-located behavioral health services, and standardized suicide risk protocols, offers a scalable, equity-focused approach. Nurse practitioners are uniquely positioned to lead these efforts by coordinating care, addressing social determinants, and embedding suicide prevention within routine primary care practice.