For me it is when red flags go up. Things like lasting hypomania, deepening depression and especially suicidal ideation. Mostly I try to manage with the meds I have and talk it through with my T, who thankfully is trained in meds, and see if the episode passes on its own. I feel terrible making emergency psychiatrist appointments for some reason. If anything I hold on too long. Usually my emergency appointments land me IP as I have waited too long. Guess there must be a happy medium between seeing your pdoc too soon and waiting too long.