Household dog ownership in the US increased from 38% in 2016 to 45% in 2022 (www.tinyurl.com/2w6np86r). This uptick has also accompanied requests for labeling pets as “emotional support animals” (ESAs) to enable pets to enter apartment buildings or public spaces where they might otherwise be prohibited (www.tinyurl.com/47mun957). In this article, I’ll discuss ESAs and how they differ from service animals.  

Service animals and psychiatric service animals 

Service animals fulfill tasks to aid patients with disabilities, like guide dogs for the visually impaired or alert dogs for seizures. The disabilities that service animals provide aid for involve significant limits on life activities. Psychiatric service animals provide aid too, such as by lighting dark rooms for PTSD sufferers, alerting others to panic attacks, interrupting compulsions, or reminding patients about medications.

Service animals are not considered pets. They are primarily working animals and are protected by the Americans with Disabilities Act (ADA). They are limited to dogs and miniature horses. Service animals are allowed to be with their owners in places where pets are often not allowed, including restaurants, shops, hospitals, schools, and hotels. 

Service animals can be trained by their owner or by training organizations. There is no law stating that a service dog has to be professionally trained, and individuals can train a dog themselves. The ADA states that if it’s unclear whether a dog is a service dog, two questions may be asked of the dog’s owner, as the owner does not have to provide documentation for the animal. The questions include: 1) Is the dog a service animal for a disability? and 2) What work or task has the dog been trained to perform? The answer to the second question confirms whether the dog is in fact a service animal for a person with a disability. 

Emotional support animals (ESAs)

Unlike service animals, ESAs can be of any species. Additionally, ESAs are not trained to perform a specific task but serve to alleviate a person’s disability due to a psychiatric illness. ESAs are not protected by the ADA, but they are protected by the Fair Housing Act, which protects against discrimination when buying or renting a home. 

ESAs are protected in private spaces (ie, rental properties) but not necessarily in public spaces. The US Department of Housing and Urban Development (HUD) recognizes that people with psychiatric illness face difficulty finding housing, and ESAs can alleviate their suffering. 

The HUD states that individuals with a psychiatric disability may request to have an ESA in their home with appropriate documentation. Housing providers are not permitted to ask about an individual’s diagnosis, nor can they request medical records, but they can require reasonable supporting documentation from a physician, psychiatrist, or licensed healthcare professional. 

There is no specific form to fill out for an ESA. Documentation does not need to be notarized or include any details about the person’s physical or mental impairments. These letters can be requested by someone who has a documented psychiatric condition and would like to live with an ESA on a property with a no-pets policy or to waive a pet deposit fee. (See a sample letter for an ESA at right.)

Traveling with an ESA was a gray area until January 2021, when the federal government ruled that airlines are not required to accommodate ESAs. As a result, most major airlines have banned ESAs. One exception is Pet Express, which provides transport services for animals. 

Will an ESA help my patient?

Although it’s popularly believed that pets help with mental illness, we really can’t say for sure. We need to distinguish between having an animal for personal comfort and having one to ease mental illness. There is mixed evidence demonstrating that ESAs or service animals alleviate psychiatric symptoms. Studies that have been published are small, underpowered, and not randomized (www.tinyurl.com/y84bvwsj).

Shifting focus from ESAs to the broader human-animal bond, pets positively affect mental health by easing loneliness and fostering social connections. Dogs, for instance, act as a social lubricant, bringing people together (Ferrell J et al, Prof Psychol Res Pre 2021;52(6):560–568). They also improve cognition, redirecting attention to positive stimuli for stress resilience (Carroll JD et al, J Am Acad Psychiatry Law 2020;48(4):509–518).

Who might benefit from an ESA?

Many people with mental illness could benefit from an ESA, such as a person with social anxiety disorder who finds it difficult to leave their home and interact with others. People with depression could also benefit from an ESA as a way for them to feel responsible for another sentient being. On the other hand, someone with depression could also neglect the needs of the animal. 

Are there any negative consequences of writing a letter for an ESA? 

When asked to write a letter for an ESA, first talk with the patient about the responsibilities of pet ownership. Keep in mind that writing an ESA letter carries with it the implication that the patient has a disability. In the view of the HUD, writing a letter without evidence of an actual disability is fraud. 

State- and city-specific regulations 

ESA laws vary by state. In California, the provider must perform a specific disability evaluation, be licensed in California, and have at least a 30-day therapeutic relationship with the patient. Florida allows an out-of-state provider to write an ESA letter but requires that the provider meet with the patient at least once in person.