Going to the ER in a mental health crisis

Emergency rooms were built for chest pain and car accidents. They are not designed for a mental health crisis, and most people who go describe it as one of the hardest nights of the whole thing.

That is worth saying plainly rather than pretending otherwise. It is also not the whole story: sometimes the ER is the right place, and going is the reason some people are still here.

When the ER is the right call

Go, or get someone to take you, if:

• you have seriously hurt yourself and need physical treatment
• you have taken something and need medical attention — this is urgent and it matters far more than any embarrassment about it
• you do not believe you can keep yourself safe for the next few hours
• somebody with you is frightened for your immediate safety

If it is that urgent, call 911 rather than driving yourself.

They have to see you. That is federal law.

This is the single most useful thing to know, and most people do not.

Under EMTALA, any hospital emergency department that takes Medicare — which is nearly all of them — must give you a medical screening examination and stabilize an emergency condition regardless of your insurance, your immigration status, or your ability to pay. A psychiatric emergency counts.

They cannot turn you away at the desk for not having a card. What happens to the bill afterwards is a separate question, and there is a guide about that.

What actually happens, in order

1. Triage

   A nurse asks why you are there. Say it directly — "I'm having thoughts of suicide" or "I hurt myself" — because vague answers get triaged as routine and you will wait longer.

2. The wait

   This is the hard part and it can be very long. You may be moved to a room with nothing in it, or asked to change into hospital clothes, and someone may sit with you. That is a safety procedure, not a judgement about you.

3. Medical screening

   Blood pressure, bloods, sometimes a urine sample. If you have taken something this part is the priority and is not optional.

4. The mental health assessment

   A psychiatric nurse, social worker or physician asks a longer set of questions. This is the conversation that decides what happens next.

5. A plan

   Most people go home, usually with a follow-up appointment or a referral. A minority are admitted. A minority are transferred to a psychiatric facility.

Boarding, and why the wait can be days

You should know this in advance because it is common and it is demoralizing when it arrives without warning.

If the assessment decides you need an inpatient psychiatric bed, there often is not one. People wait in the ER — sometimes for a day, occasionally for several — while a bed is found somewhere, possibly in another town. This is called boarding, it is a well-documented failure of the American system, and it is not happening because of anything you did.

If it happens: ask what is being done to find a bed, ask whether the plan can be revisited, and ask whether an intensive outpatient program would do instead. You are allowed to ask.

What to take with you

• a phone charger, and a book or headphones — the wait is the enemy
• a list of any medication you take
• your insurance card if you have one, and go anyway if you do not
• somebody, if there is anyone. It changes the night.

What to say

If you cannot get the words out, write it down and hand it over. Nobody minds.

Things worth saying, if they are true:

• how long it has been going on
• whether you have a plan to keep yourself safe, and whether it is holding
• what you are afraid will happen if you tell them
• that you would like to know what they are deciding and why

That last one matters. You are allowed to ask what is being considered, and to be told.

Will they hold me against my will?

Usually not. Involuntary holds are for a specific and fairly narrow situation, and disclosing suicidal thoughts is not automatically enough on its own. This has a whole guide, because the fear of it stops more people getting help than almost anything else.

Alternatives to the ER

Increasingly there are options that are not this:

• 988 can talk through whether the ER is what you need at all
• Mobile crisis teams come to you in many counties — 988 can tell you
• Crisis stabilization units and psychiatric urgent care exist in some cities and are far better suited than a general ER
• Your own clinician, if you have one and it is a weekday

If none of those is available and you are not safe, go. An ER on a bad night is better than being alone on a worse one.