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Among emergency department (ED) mental health and substance abuse (MHSA) patients, we sought to compare mortality and healthcare utilization by ED discharge disposition and inpatient bed request status.A retrospective cohort study of 492 patients was conducted at a single University ED. We reviewed three groups of MHSA patients including ED patients that were admitted, ED patients with a bed request that were discharged from the ED, and ED patients with no bed request that were discharged from the ED. We identified main outcomes as ED return visit, re-hospitalization and mortality within 12 months based on chart review and reference from the National Death Index.The average age of patients presenting was 30.5 (SD16.4) years and 251 (51.0%) were female patients. Of these patients, 216 (43.9%) presented with mood disorder and 93 (18.9%) with self-harm. The most common reason for discharge from the ED after an admission request was placed was from stabilization of the patient (n = 138). An ED revisit within 12 months was significantly higher among patients discharged who had a bed request in place prior to departure (54.0%, p < 0.001), than those discharged from the ED (40.9%) or admitted to inpatient care (30.5%). The rate of suicide attempt and death did not show statistical significance (p = 0.55 and p = 0.88).MHSA patients who were discharged from ED after bed requests were placed were at greater risk for return visits to the ED. This implicates that these patients require outpatient planning to prevent further avoidable healthcare utilization.