While research has identified general utilization and cost of emergency care for mental health and substance abuse (MH/SA) services, little research specifically addresses rural utilization, and rural populations at greater risk of utilizing the emergency department (ED) for a MH/SA diagnosis. Utilizing data from the Healthcare Cost and Utilization Project's (HCUP's) State Emergency Department Databases (SEDD) for seven states, researchers explored, and describe in this brief, the use of the ED for MH/SA among Urban, Large Rural, Small Rural, and Isolated Small Rural residents. The proportion of ED visits with a primary MH/SA diagnosis increased nationally. While results indicate that utilization is lower among the more rural U.S. residents, individuals utilizing the ED for MH in rural communities share different characteristics than those in urban areas, which subsequently may impact cost of care, and proposed interventions.