Objective

To determine whether the Office of Mental Health (OMH) implemented the recommendations made by the New York State Suicide Prevention Task Force to facilitate greater access, awareness, collaboration, and support of effective suicide prevention activities. The audit covered the period from April 2019 through May 2025.

About the Program

Suicide is a complex issue related to multiple risk factors, including relationship, job, school, or financial concerns; mental illness; substance use disorder; social isolation; historical trauma; and barriers to health care. OMH’s mission is to promote the mental health of all New Yorkers, with a particular focus on providing hope and recovery for adults with serious mental illness and children with serious emotional disturbances. OMH prioritizes saving lives and reducing the devastating impact of suicide on individuals, families, and communities. OMH’s Suicide Prevention Center of New York (SPCNY) is the State’s lead entity in suicide prevention. In September 2016, SPCNY issued its 2016-17 State Suicide Prevention Plan (Plan) entitled “1,700 Too Many.” Based on 2014 data, the Plan highlighted suicide as a significant national public health problem, reporting that over 42,770 persons died by suicide nationally and that it was the tenth leading cause of death among all age groups.

According to Centers for Disease Control and Prevention (CDC) data, as of February 2016, New York State had one of the lowest suicide rates in the nation, at 8.6 suicides for every 100,000 individuals, compared to 13.4 per 100,000 nationally. However, New York saw a 32% increase in suicide deaths over the previous decade, with suicide rates showing significant disparities among different groups and consistently ranking as one of the leading causes of death for young people.

In November 2017, the State convened the New York State Suicide Prevention Task Force (Task Force). The Task Force comprised a diverse group of experts to review current services and policies, identify gaps and promising solutions, and make recommendations to facilitate greater access, awareness, collaboration, and support of effective suicide prevention activities. In April 2019, the Task Force released a report, “Communities United for a Suicide Free New York” (Task Force Report), which focused on reviewing current programs, services, and statewide suicide prevention policies in order to identify gaps in resources and strengthen coordination between State and local partners, with an emphasis on vulnerable populations at greater risk for suicide. The Task Force Report included a total of 27 primary recommendations, many of which included multiple sub-recommendations. Many of the recommendations issued by the Task Force required collaboration between OMH and other public and private entities, including communities, hospitals, mental health providers, health care systems, and the Department of Health (DOH). OMH was responsible for coordinating a Steering Committee open to other State agencies with important roles in suicide prevention, such as the Office of Addiction Services and Supports and DOH, to guide the statewide implementation of the Task Force’s recommendations.

Key Findings

While OMH has made progress in addressing the recommendations in the Task Force Report, since the Task Force’s inception in 2017 and through 2023, New York’s suicide rate has remained relatively unchanged, with COVID-19 era stressors likely contributing to the lack of progress. OMH has addressed portions of the Task Force’s recommendations to enhance suicide prevention efforts in New York State, including identifying and incorporating core elements of suicide prevention into its regional framework, involving key stakeholders, and providing guidance to schools on developing policies for suicide prevention for planning and programming. However, OMH could do more to ensure the State will achieve its goal of reducing suicide mortalities. For example:

• OMH does not currently have any processes or benchmarks to track or monitor the implementation of the Task Force recommendations and their outcomes (if any). Ongoing evaluation of Task Force recommendation implementation would allow OMH to understand individually, or as a whole, whether actions are moving the State toward its overall prevention goals.
• OMH could improve documentation of the efforts OMH takes to implement Task Force recommendations to substantiate decisions and preserve a history of decisions and actions taken to justify or drive future actions to implement the Task Force Report’s recommendations.
• OMH does not track efforts made by other agencies to improve the accuracy and completeness of core suicide surveillance data, which makes it difficult to coordinate and facilitate data sharing and to provide direction for statewide, regional, and local efforts.

OMH officials state they are committed to taking actions to reduce suicide mortality and morbidity and that new tools and sources of support to address those challenges have been developed in recent years. However, OMH officials expressed that they face certain challenges in implementing the recommendations, including no additional funding or statutory authority tied to the initiative and that actions to reduce suicide mortality and morbidity rely primarily on voluntary partnerships. Further, nearly a year after the Task Force released its Task Force Report, in March 2020, the COVID-19 pandemic was declared, which derailed many of OMH’s efforts, as it needed to focus its resources to respond to the pandemic.

Key Recommendations

• Develop and implement practices to monitor, evaluate, and document efforts to implement Task Force and/or other specified recommendations for suicide prevention activities.
• Develop practices to improve accuracy and completeness of core suicide surveillance data and information sharing.