Increases in emergency department (ED) presentations for mental health conditions continue to challenge the national mental healthcare infrastructure, often resulting in ED boarding. However, limited prior studies capture the perspectives on mental healthcare of those experiencing prolonged boarding in the ED (≥ 24 hours stay) for mental health conditions. We aimed to assess patient perspectives on acute mental healthcare among individuals boarding in a general ED in a rural state. We performed semi-structured interviews of adults (≥18 years old) presenting with a primary mental health condition boarding in a general ED for at least 24 hours. An interview guide was developed a priori, and a trained study team performed the interviews. A thematic analysis was conducted by two independent coders. A coding tree was developed through an iterative process that included double-coding transcripts and monitoring of inter-rater reliability. Fifteen patients were interviewed to reach saturation. Ages ranged from 22 to 65. Analysis revealed several key themes including the environment of the ED, interactions with family members and staff, communication regarding the plan of care, patient perceptions of autonomy and respect, and mental healthcare services provided outside the ED. Our study revealed that adults encounter significant challenges to access timely acute mental healthcare in the ED in a rural state. Participant recommendations for improvement included increasing the availability of therapy while in the ED and providing a physical environment that is more welcoming. Community, hospital-based, and statewide quality improvement and public policy strategies should be considered to address the identified challenges.