General hospital ERs are faced with an increasing number of patients with major psychosocial problems. The current study collected data on all patients who came into a general hospital ER and who were identified by the nursing staff as having major psychosocial problems. Of all patients seen in the ER, 5.8 percent were patients who were considered to have major psychosocial problems, but only 52 percent of the study patients were officially registered. Many of these patients were seen in the early morning hours when fewest ER and community resources were available. Some suggestions are made about why such patients continue to use the general ER and how staff can learn to more effectively treat this difficult patient population.The role of the modern emergency room (ER) has increasingly expanded to provide both emergency and nonemergency medical care (Bassuk & Gerson, 1979;McCarroll & Skudder, 1960). This paper presents data from a study of a general hospital ER that examined 1) the number of patients identified by an ER nursing staff as having major psychosocial problems; 2) the number of these patients that was already in the mental health system; 3) the presenting problem of these patients; 4) the number that was never registered into the ER and would, therefore, have gone uncounted in a chart review; and finally 5