A group of emergency physicians is rejecting “excited delirium”, a controversial term used by some police officers, clinicians, coroners and court experts to explain how an agitated person can die in custody through no fault of the force used to subdue them.
Dr Michele Heisler, medical director of Physicians for Human Rights, says the move by the American College of Emergency Physicians (ACEP) will take agitated delirium off the table in court cases. “This is the last professional medical or psychological or psychiatric association to reject the term,” she said.
Excited delirium has been described by other medical associations as “linked to racism” and used disproportionately in the deaths of black people. It was cited in one of the most high-profile cases in recent years: the death of George Floyd in 2020.
ACEP’s board of directors confirmed on Thursday that its 2009 white paper on excited delirium syndrome is “outdated and does not represent the College’s position based on the latest science,” according to a statement on the organisation’s website.
“The term excited delirium should not be used by the broader medical and public health community, law enforcement organisations, and ACEP members serving as expert witnesses testifying in relevant civil or criminal proceedings,” the statement said.
This decision officially withdraws the board’s approval of the paper.
Joanna Naples-Mitchell, US research consultant for Physicians for Human Rights and co-author of a 2022 report that traced the history and impact of the term and showed how excited delirium was often cited in deaths in police custody, said ACEP’s move was “a tremendous turning point”.
The white paper was “extremely influential”, she said, and one of the main reasons the term could be used in court.
“Part of the reason why this paper is so damaging is because not only has it been cited in court, but the content of the paper puts forward this definition of signs and symptoms of agitated delirium, which includes terms that have racist overtones and can actually encourage law enforcement to use excessive force, including saying that someone with delirium may have superhuman strength and [be] impervious to pain and may not actually be able to respond to typical non-lethal uses of force,” she said.
The paper was often used to support evidence in court, including in expert testimony at the trial of Derek Chauvin for the murder of Floyd. Experts would sometimes cite it to argue that the death of someone in custody was the person’s own fault rather than the actions of the police.
ACEP considered the syndrome to be a sub-category of delirium. Someone with excited delirium was described in studies as being agitated, aggressive or disoriented, and it was thought that this heightened emotional state could lead to their death.
Technically, agitated delirium has never been considered an official diagnosis because it isn’t listed in the reference materials used by mental health professionals or in the codes that health care facilities use to record a diagnosis for insurance purposes and research. There is no blood or diagnostic test to detect it. The 2022 Physicians for Human Rights report concluded that the term is “scientifically meaningless”.
There is no national database tracking cases of ‘agitated delirium’, but one study found that between 2010 and 2020, “there were 166 reported cases where a person died in police custody and agitated delirium was listed as a possible cause of death”. Black people accounted for 43% of these deaths, despite making up only 13% of the US population, according to the US Census.
The term received additional attention after the death of Elijah McClain, a black massage therapist who died in 2019 after being placed in a carotid hold by police. Paramedics had also injected him with ketamine. One of the officers involved in the incident was found guilty of involuntary manslaughter and assault by a jury on Thursday, while another was acquitted. Two paramedics, who have pleaded not guilty, are also due to stand trial in the coming weeks.
In Floyd’s case, the Minneapolis police officer who held down his ankles was overheard saying, ‘I’m just worried about excited delirium or whatever’. In court, a police surgeon testified that Floyd did not meet the criteria.
In 2020, the American Psychiatric Association took a position against the diagnosis, saying that it was “non-specific” and “lacked clear diagnostic criteria” and that it should not be used until such criteria were validated. The organisation also called for the development of evidence-based protocols for the use of ketamine by first responders in emergency situations.
“It is concerning that it can often be used retroactively to explain the use of force in law enforcement contexts,” Dr Debra Pinals, chair of the APA’s Council on Psychiatry and Law, told the association’s Psychiatric News at the time of McClain’s death.
Also in 2020, the American Medical Association adopted a policy opposing excited delirium as a medical diagnosis. The group warned first responders against using pharmacological interventions without a legitimate medical reason.
The American Medical Association said its policy came about because of a pattern of police using the term and pharmacological interventions like ketamine as a “justification for excessive police force, disproportionately cited in cases where black men die in law enforcement custody”.
In February, the American College of Medical Toxicology said it was time to “discontinue the use of this term because it is used in multiple different contexts with different underlying causes and has become associated with racism”.
In April, the National Association of Medical Examiners issued a statement urging its members to stop listing excited delirium as a cause of death.
This week, California Governor Gavin Newsom signed legislation making the state the first to ban excited delirium as a diagnosis and cause of death.
ACEP has been studying the issue for years. In 2021, a task force decided that the organisation should not recognise the use of ‘excited delirium’, arguing that it should no longer be used in clinical practice. Disavowing the paper, as the group did this week, makes the statement stronger, and experts say this means it should no longer be used in court.
The group does, however, recognise a similar term, “hyperactive delirium with severe agitation”, which it says is a “potentially life-threatening clinical condition characterised by a combination of vital sign abnormalities, marked agitation, altered mental status and metabolic derangements”.
When dealing with someone with hyperactive delirium, the organisation advised in April, first responders should focus on reducing stress, preventing physical harm and getting the person to a hospital where they can be treated by an emergency physician.
Heisler, who is also a professor of internal medicine and public health at the University of Michigan, says agitated delirium “is just an unsubstantiated concept and should never have been used as a diagnosis – and certainly not as a cause of death”.
Heisler says she hopes ACEP will now work to educate its members about the policy change to ensure the term is never used again.
