Excited delirium: a deadly term finally laid to rest

George Floyd. Angelo Quinto. Elijah McClain.

All three men were killed by lethal force inflicted by the police, and all three deaths were initially blamed on something called “excited delirium.” For years, law enforcement officers and other first responders were taught that people suffering from this so-called medical condition were uncontrollably strong, irrational, and required the most severe measures to be subdued.

The diagnosis became a weapon that helped justify police actions. It became a standard defense to counter charges of police brutality. And yet it wasn’t based on real evidence.

Now the American College of Emergency Physicians (ACEP), the group that wrote and endorsed a controversial 2009 white paper that led to the widespread legitimization of this pseudo-condition, has admitted it was wrong to do so.

ACEP is late to join the group of many prominent medical organizations that have rejected this unscientific, deeply problematic, and racist description of a made-up condition. Nevertheless, for emergency medicine doctors like me, this is a long-awaited admission.

In the same week, California became the first state to ban “excited delirium” as a cause of death on autopsy reports. The legislation also prohibits law enforcement officers from using the term to describe behavior. Other states will likely follow.

As an emergency physician who cares for distressed, sometimes unnerved, patients daily, and a researcher who thinks a lot about structural causes of health inequities, I am relieved and optimistic. But it will require more than ACEP’s withdrawal and state bans to undo the damage that “excited delirium” has done.

The term “excited delirium” had been used inconsistently for decades before the 2009 ACEP white paper. However, the codification by a credible group of emergency physicians gave it so much influence. The original report alleged that excited delirium syndrome is “a unique syndrome” identified by characteristics that included “pain tolerance,” “agitation,” “police noncompliance,” and “unusual strength.” It provided guidance on the pre-hospital and emergency department management of the condition, warning law enforcement officers that traditional tools available to them to take control would not be effective and that “any interaction with a person in this situation risks significant injury or death to either the LEO [officer] or the subject.” This primed clinicians and non-clinicians alike to fear distressed individuals and to view quickly applied, forceful physical restraints as the only option.

Over the next 14 years, the report, which was not based on scientific literature and did not undergo the peer-review process to ensure accuracy, was used repeatedly in police and pre-hospital training and was cited by defense attorneys in numerous cases of excessive force and wrongful deaths by police. The majority of the deaths in police custody attributed to “excited delirium” are among Black and Latinx people.

While most emergency physicians have stopped using the diagnosis in clinical practice, not all have. I still occasionally hear it, or other similarly vague terms, used by colleagues and by police to describe a person in extreme distress, and I always cringe. It is dangerous clinically, as it can cause us to prematurely stop investigating what is actually causing the patient’s condition. A head bleed after a fall or an assault, for example, could also cause confusion and agitation, and could be deadly if missed.

The term also feels racially and socially coded. Many studies, including one of my own, have shown that Black patients are more likely to be chemically sedated or physically restrained for agitation in the emergency department compared with their white counterparts.

Emergency medicine is an extremely difficult job. We take care of anyone, at any time, and make complex decisions with relatively little information, overstretched staff, and chaotic, loud, sometimes violent, workspaces.

We are a specialty of the worst-case scenario. Through history, physical exams, blood work, and other tests — our mission is to prove to ourselves and our patients that we have thought about and ruled out the most dangerous and deadly conditions, no matter how rare or unlikely.

This approach is ingrained in our training. Chest pain is a heart attack until you can be assured it is not. Numbness is a stroke. A fever is sepsis. But at some point, we came to accept that extreme psychiatric distress could be due to a made-up “syndrome.” One that had no understood cause or physiology. No standard diagnostic criteria. Based on racist tropes. Used to justify the murder of Black and brown people at the hands of the state.

ACEP withdrawing approval of the report was overdue and necessary. The consequences extend far beyond the emergency department. Brooks Walsh, an emergency physician in Connecticut who authored the resolution that led to this move, told me: “We’ve delivered two clear messages from ACEP. First, the organization no longer stands behind the 2009 white paper. From here on, physicians acting as expert witnesses can no longer point to ACEP as having ‘formally recognized’ this false diagnosis, and can no longer describe the 2009 paper as an authoritative or an official position of the college. We hope this will play a large role in bringing science back into the courtroom.”

The decisions by ACEP to repudiate the 2009 report and by the state of California to abandon the term are not about semantics or the policing of words. These are public acknowledgments that promoting an unsubstantiated and unscientific term as a clinical “syndrome,” one that fosters fear and promotes harmful actions, is wrong and dangerous.

I am proud of my specialty for taking this step. But the impact of these decisions will not manifest overnight. The unlearning and de-implementation, by clinicians and law enforcement alike, will take time. In fact, it takes on average 17 years for evidence to change clinical practice.

How long it takes to recognize and unlearn when biases, stigma, and racism are influencing clinical decision-making is less understood. The interruption of the racialized criminalization of distressed individuals, both in the hospitals and on the street, will require evidence-based interventions, such as trauma-informed care models and diversion programs.

Developing non-police responses to psychiatric emergencies will require committed resources from local agencies. We also need to see radical change and investment in the social and health care systems that inadequately address mental health, substance use, and housing, which are necessary to prevent people from experiencing such distress in the first place.

And what about repairing the damage that has already been done to patients and families? What obligation do we have in emergency medicine, and in health care more broadly, to not just own up to our errors but to actively mend them?

To start, our health care institutions should prioritize scaling up staff and resources in the clinical spaces (emergency departments and psychiatry) most likely to interact with undifferentiated, distressed patients, who can be further disturbed by the long waits and overextended staff. When there is an overlap between law enforcement proceedings and emergency care in the hospital setting, we should develop guidelines that are based on evidence and centered on patient rights and autonomy, while ensuring local laws are followed. Our professional organizations must prioritize supporting research and quality improvement efforts that document and intervene on disparities in the management of agitated patients.

None of this is to take away from the genuine progress we’ve seen. But these changes will not undo the horrific killings of George Floyd, Angelo Quinto, Elijah McClain, and, unfortunately, many others. Now we must start down the path forward to preventing future tragedies.

Utsha G. Khatri, MD MSHP is an assistant professor of emergency medicine and population health and policy at the Icahn School of Medicine at Mount Sinai.