An ER Psychiatrist Analyzes The Pitt’s Mental-Health Struggles

The Pitt is the television darling of 2025 — and rightly so. It successfully reinvented the procedural for the streaming age. Its hyperrealistic portrayal of what a hospital emergency department actually looks like is resonating with medical professionals everywhere. And it reminds the masses, once again, that Noah Wyle is a babe. But much like the doctors and medical students bouncing around Dr. Robby’s ER, The Pitt has flaws, too — for instance, the way the show handles mental health, whether it’s nicknaming an unhoused patient with schizophrenia “the Kraken” or questioning a beauty influencer with mercury-poisoning-induced psychosis.

“I think it treats mental health as a bit of an afterthought,” explains Dr. Kayla Simms, an emergency psychiatrist and clinical faculty with the Department of Psychiatry at the University of Ottawa, who’s a huge fan of the show but takes reasonable issue with its underlying assumptions about the relationship between emergency medicine and psychiatric care. Simms has eight years of experience working in ERs, with specific expertise in suicide risk assessments, involuntary stays, and verbal-de-escalation methods. Watching The Pitt, she sees tension between the series’ desire to reflect a stigma around psychiatric treatment that really does exist in emergency rooms and its ability to play out a mental-health narrative that isn’t simply in service to a doctor’s character arc.

The Pitt has been described as being perhaps the most realistic depiction of what an emergency room looks like. Does that ring true to you?
Absolutely. I was instantly compelled by the portrayals of the staff, the residents, the medical students, the charge nurse — the medical content itself was hyperaccurate for me, as a psychiatrist. I also immediately noted the undertones of mental distress the staff members were under, which I thought was really authentic.

But there are ways the show handles mental health that struck you as a little wanting.
I think it treats mental health as a bit of an afterthought. As a provider, I’m used to seeing mental health depicted in that way, and there’s an element of accuracy to that because the stigma is real. Mental illness gets the short end of the stick, especially in medical storytelling, and it’s stark here because The Pitt gets so much accurate that it feels like a missed opportunity to represent mental-health care in a way that really emulates the standard of care.

The first major example I can think of as being a little thorny is the unhoused person who shows up with a nest of rats under his coat. He’s eventually depicted as suffering from schizophrenia, but he also comes off as an uneasy spectacle. How did that scenario strike you?
From the very first moment we’re introduced to that character, he’s referred to as “the Kraken,” a kind of monster lying in wait. He’s presented as a problem to be dealt with, not a person in distress.

So here we have a man in distress, but the show depicts him as a problem in the background. Everyone is trying to forget about him. There’s a bit of a lag in treating him compared to how nursing staff and physicians respond to other issues in the emergency department. One nurse says he even forgot to give him medication, and now everyone’s debating how they’re going to restrain him.

We see Dr. Robby as a kind and compassionate guy who doesn’t hesitate to step in to help, but when the charge nurse tries to bring him into this case, he walks away. So we end up with the medical student, Dennis Whitaker (Gerran Howell), getting reluctantly pulled into the situation and handed a needle, and what they proceed to do is they enter the room — with no verbal engagement — and Dennis plunges the injection into the patient with a battle cry.

It’s so theatrical and dramatic. It’s nothing that resembles the kind of treatment we aim for in psychiatric emergencies. I thought it was really dehumanizing.

What role does an emergency psychiatrist like yourself play in a real ER?
When patients come in, they’re usually triaged by a nurse who gets involved in their care, and an emergency physician will become the main person to look after them. If the physician detects there’s an indication for psychiatric involvement, whether that’s overt or covert, they’ll consult us.

For example, if someone is obviously in a state of crisis — they’re suicidal, acutely manic, acutely psychotic — they will be referred to see the emergency psychiatrist. But sometimes it’s more subtle. They might come in primarily complaining about back pain, but a physician eventually realizes they actually have a plethora of delusions: an alien is living in their stomach, their brain has been replaced by a computer — things like that. In that case, they’ll be referred to psychiatry.

Are emergency psychiatrists physically posted within the ER, or are they usually somewhere else in the hospital?
It depends on the hospital structure. I’m usually in the ER, but there are some hospitals that don’t have a dedicated ER psychiatrist. In that case, the psychiatrist who manages the inpatient unit and whoever’s on call would have to come down to see the patients in the emergency department. Usually, we interface with the ER physicians, come in as consultants, and provide a psychiatric opinion for treatment. We help to discharge them or decide if the person needs to be admitted to the inpatient mental-health unit.

In a real-world emergency room, what would’ve been the protocol with the unhoused patient?
We would have attempted verbal de-escalation. We try to limit coercive means of treatment. That includes chemical and physical restraint, which we see in the show are used as the first line of treatment, even though the guidelines say they should be the last resort after verbal strategies have failed.

If The Pitt were to depict that patient with a more humanistic quality, you’d actually decrease the amount of resources thrown at him. The scene saw six different staff members pulled from their positions to restrain him. But if you move to engage a patient verbally, you’re looking at something more one-on-one.

Another thing we try to do is offer choices. People in an acute psychiatric crisis often don’t know the options available to them. Simple things like, “Do you want the door open or closed? Lights off or on? Do you want a chicken sandwich or an egg-salad sandwich?” (No one wants tuna.) Providing a locus of control for this person is important, because if we think back to how that patient woke up in soft restraints on a gurney, that’s a moment when all control has been stripped from him.

The response you outlined there does come through in another situation, when Dr. Melissa King (Taylor Dearden) treats a patient with autism who’s bothered by the stimuli in his room. How did you feel the show rendered that interaction?
That was a really good model. You can see that Dr. Langdon (Patrick Ball), the senior resident, didn’t have those skills, and he learns from Dr. King. What she’s doing really isn’t rocket science, but it eludes him even with all his emergency-medicine skills: this basic task of sitting with someone and paying attention to their needs and communication styles.

What did you think of how Whitaker’s situation with the unhoused patient was resolved?
It was interesting to me. They wrap it up nicely with Whitaker meeting the patient, and he initially accuses him of using meth. The patient says, “No, I’m actually sober. It’s just been hard. I don’t have stable housing. I can’t afford my medication.” And the social worker (Krystel V. McNeil) guides Whitaker to meet people where they’re at and to join the street team to help these people in a different way.

It’s a neat resolution, but the arc now is all about Whitaker and the triumph of his learning. Psychiatric patients don’t get tidy resolutions. He doesn’t have access to stable housing; he can’t afford his medication. What we see there is what we call “revolving-door care,” where the person leaves the hospital in a better mental state but they’re not going to be able to take their medication. Unstable housing is going to lead to chaos in their life, and they’re going to end up back in the emergency department in the same situation over and over again.

To your earlier observation about Dr. Robby evading the patient with schizophrenia, could you argue that it’s an accurate depiction of how ER teams generally have strained relationships with mental-health situations?
I’ve thought a lot about this. On the one hand, I want to expect better from the show. I know they worked with a lot of professional consultants to make this, so my initial thought was yes, this was a move to accurately portray the strained relationship they have to mental-health care. Emergency departments are not set up to be the frontline providers for acute mental-health crises, yet they are because there are lots of systemic gaps and constraints. So I do feel a deep empathy for where Dr. Robby’s character is coming from. Perhaps it is accurate to portray a felt sense of helplessness with these patients coming to their emergency departments, taking up these resources, knowing that it’s not an ill will against this person with mental illness.

Yet I think the show exemplifies, beyond accuracy, the standard of care when it comes to, say, handling gender and racial inequities. Like when Dr. McKay (Fiona Dourif) and Victoria (Shabana Azeez) are treating a trans individual who comes in, and at the very end of the clinical interaction, Victoria mentions that she’s changing the patient’s pronouns in the system. People with trans and gender-diverse experiences who come into hospitals often report there is so much trauma perpetuated by these health-care interactions — to the degree they don’t see themselves in the system. I don’t think those interactions are what we would typically see in a busy ER, yet time is taken to make sure that those are represented with such compassion and care.

So The Pitt goes beyond total accuracy in those moments to demonstrate what we could do. Which leaves me wondering, Why did mental illness get the short end of the stick? Because we know that evidence shows that TV portrayals of mental illness do impact patients’ feelings about themselves, their loved ones, and their willingness to seek care and support. So I do think there are harms that are perpetuated by what they depicted accurately or not.

Would a normal ER shift encounter more patients with mental-health needs than what appears in this season? Or does it depend on the day?
There’d be so many more, I have to say. Granted, The Pitt depicts a trauma center, so maybe those patients are getting diverted to a center with more emphasis on mental health, but on a day-to-day basis, there would be a lot more mental-health-related patients to lead to that felt sense of exhaustion all the staff are experiencing.

What are the most common kinds of mental-health cases we’re not seeing on the show?
At least in my city, I see a lot more cases of suicidal ideation. More challenges coping with the day-to-day. More addiction and way, way more substance-use-related issues. The Pitt actually does a lot with substance issues, and they do so in pretty interesting ways. There’s the story line involving a group of university students who take Valium laced with fentanyl and end up in a state of overdose. I thought that was a well-done example to demonstrate the opioid crisis as far-reaching and transcending socioeconomic demographics, because they are not the majority of people we see afflicted by substance-use issues.

Later in the season, a patient who’s a beauty influencer gets admitted with what initially appears to be major mental-health challenges. The case produces a distinct tension between Dr. Robby and Dr. Mohan (Supriya Ganesh): He’s constantly nudging her for a psych consult; she’s resistant. What does that conflict convey to you?
There are a couple of things with Dr. Mohan that specifically bring to light the show’s feeling around psychiatry. Going into that scene, we already know that Dr. Mohan is being criticized for what Dr. Robby perceives as working at a slower pace than her peers. At one point, he offhandedly makes a remark that she might be better suited for psychiatry, which is frankly insulting, because it’s implying psychiatry is a fallback for people who can’t handle the real work of medicine. Yes, we are a slower breed because of the nature of the work we do. It takes time to gather psychiatric histories to document our psychiatric reports. But that’s not a character flaw.

I also thought it was really interesting because he’s pressuring her to call psych and she’s resistant. She’s trying to see the whole picture. This comes up a lot between ER and psychiatry: Someone comes in the door and they appear, to the ER physician, to be acutely psychotic. The physician has not done any blood work or any imaging or a urinalysis, and this is the person’s first time presenting with this episode. In those situations, the term we use is medical clearance. Have we confirmed and ruled out other contributions that could be causing these symptoms before we say this is psychiatric and get this person on lifelong antipsychotics, possibly?

What Dr. Mohan ultimately identifies is mercury poisoning, which is very rare in medicine. Ultimately, she’s vindicated in that moment for having done this more thorough medical workup and resisting Dr. Robby’s critique that she should have called psychiatry beforehand. It’s never fully reconciled, though. He kind of nods at her and maybe says “Good job,” but that’s a pretty tremendous find.

I read that lack of reconciliation as a reflection of the fact that Dr. Robby feels constantly compelled to move his ER on to the next thing. There’s only so much time to celebrate.
To be fair, a slow ER doctor is a problem — I don’t want to undersell that. Dr. Mohan is great, and there are moments where she really misses the mark. For example, there’s a gentleman who comes in and is clearly addicted to opioids but denies that, and she covertly gives him Suboxone, which is an opioid-agonist therapy. Dr. Robby rightly reams her out for that. These are realistically flawed characters, and I think some of the ways their flaws come out are in how they manage these mental-health patients.

One of the biggest story lines in the series revolves around David (Jackson Kelly), a young man who Dr. Robby and Dr. McKay worry may be a threat to his classmates. I’ve heard they could have gotten a 72-hour hold on David purely based on the threats in the list he made. Does that track with you? Or does it differ from state to state?
It differs from state to state. This one hits on an ethical gray area where someone isn’t your registered patient but you’ve learned something about them with a duty for mandatory reporting that you feel you have to act on.

There are lots of interesting elements in that situation. I’m not convinced that the mother is okay. Someone making themselves sick to bring a son they’re worried about to the hospital speaks to a state of complete desperation. She probably needs additional support herself. But the situation with David exists right on the line: the information that comes forward, the list, the genuine concerns this mother has that he might hurt someone. What I like to think about in those instances is, Well, let’s say I didn’t intervene and he does hurt the women on those lists. What kind of situation do I produce?

I like to practice with caution and safety in the front of mind at all times. If I put him on a 72-hour hold, and we assess him and can help him, awesome. If he doesn’t let us help him, intervention is minimal. The stay in hospital doesn’t lead to much, but maybe I’ve prevented a lot of unnecessary death and harm.

Something I want to say about holding people against their will: There’s a feeling or trope — and this is emphasized by the patient they called “the Kraken” — that psychiatry is inhumane, that we hold people against their will, that we restrain them, that we detain them. This is a stereotype because those systems of holding people in hospital involuntarily are sometimes the only means by which we can actually intervene and get them better. I have seen people go from being so sick with schizophrenia and living on the streets to being housed and having jobs — and involuntary holding was a necessary step in their care. There are times when intervening that way does really get people the treatment and the care they deserve.

Do you hope to see what comes of David’s situation in season two?
Of course! I’m very interested in that. I hope that these outcomes for all of these people are worth it. So much of the show circles around mental distress. In the first scene of the show, we see Dr. Robby meet Dr. Abbot (Shawn Hatosy), the attending who was on overnight and had a terrible shift, on the roof, and both covertly and overtly, they’re talking about suicide. From the get-go, there is this tone of mental distress, but it only happens in secret. Dr. Robby cries in a room in secret. Dr. Langdon is addicted to pills in secret. His colleague is on the roof thinking about suicide in secret. All of this mental distress happens behind closed doors in the show, and there are very few moments when it’s allowed to be brought to the surface. I do think that is an accurate depiction of what it is like to be an emergency physician moving from case to case to case with no time to engage with your emotions.

I’m curious: Does Canada handle emergency care any better than the U.S.?
The Pitt does a great job depicting what’s really happening with wait times and ER volumes in the U.S., and that is a real struggle for us, too. In Canada, we have a public-health-care system, which is a real gift, but it also means that our ER wait times are sometimes atrocious. Often, I see patients who have waited 14 hours before they’re even seen by a physician.

It’s funny because Americans tend to have a very rosy view of the Canadian health-care system.
There are going to be pros and cons in both. I guess the main benefit is that when the person leaves a hospital here, they don’t get a bill. But time is its own currency. If you’re spending 14 hours waiting to see the doctor, you’re paying with something.