Board Adopts Position Against Diagnosis of ‘Excited Delirium,’ Police Use of Ketamine

The term “excited delirium” is nonspecific, lacks clear diagnostic criteria, and should not be used as a diagnosis until such criteria are validated, according to a position statement adopted by the APA Board of Trustees in December 2020.

The position statement notes that the concept of “excited delirium” (also referred to as “excited delirium syndrome”) has been invoked to explain or justify injury or death to individuals in police custody, and the term excited delirium is disproportionately applied to Black men in police custody. Moreover, persons being detained by the police and described as having “excited delirium” have frequently received medication—including ketamine—from emergency medical technicians (EMTs) intended to rapidly sedate them.

The statement calls for a comprehensive investigation of how and under what circumstances the term “excited delirium” is used, including in interactions with law enforcement and in other out-of-hospital contexts—and for the development of evidence-based protocols for administration of ketamine in emergency medical situations outside the hospital.

Those protocols should allow use of these medications only for treatment purposes in medically appropriate situations and should explicitly bar their use to achieve incapacitation solely for law enforcement purposes.

Debra Pinals, M.D., chair of the APA Council on Psychiatry and Law, said the statement stemmed from questions and concerns about the 2019 death of Elijah McClain, a 23-year-old Black man who died after being placed in a chokehold by police and being administered ketamine. “APA is concerned that the term ‘excited delirium’ does not reflect a diagnostic category recognized by DSM-5 and has not had the validity testing of other diagnoses,” Pinals told Psychiatric News. “It is of concern that it can be used often retrospectively as a way to explain use of force in law enforcement contexts.

“We call for attention to the use of ketamine for law enforcement purposes and state that given the risks of this medication, there should be clear guidance on its use from medical professionals.”

Past APA President and council member Paul Appelbaum, M.D., said the council will monitor the evidence for how the term “excited delirium” is being used and how people labeled as having excited delirium are being dealt with, especially when in police custody.

“Excited delirium appears to be used in a nonspecific way, often to refer to people who are agitated and difficult for the police to control,” Appelbaum told Psychiatric News. “Moreover, ketamine, which has been embraced by many police departments and EMT/paramedic agencies as a specific means of controlling excited delirium, is reported to have a high incidence of adverse effects, including respiratory depression requiring intubation. But the evidence base on how the term is applied and on the use of ketamine and its consequences is weak.”

Appelbaum was featured in a “60 Minutes” story that aired December 13, 2020, about use of the term “excited delirium.”

The position statement notes that the American College of Emergency Physicians has explicitly recognized excited delirium as a medical condition, but that the criteria are unclear, and there have been no rigorous studies validating excited delirium as a medical diagnosis. DSM-5 recognizes “delirium, hyperactive type,” but the symptoms of this condition differ in many ways from the symptoms typically attributed to excited delirium.

Pinals said, “It is our hope that there will be further discussion among medical associations to help understand the complicated dynamics in crisis situations and the use of appropriate medications by medical professionals and that this should be explored particularly related to individuals with mental illness and substance use disorders.

“Issues of equity and disparities should also be examined,” she continued. “We have previously adopted positions that call for more training and collaboration between law enforcement and mental health professionals for improved responses overall.”

In a November 2020 letter to the Drug Enforcement Agency, APA CEO and Medical Director Saul Levin, M.D., M.P.A., expressed APA’s concern “about the use of ketamine with individuals solely for the purposes of sedating them when being detained by the police and described as having ‘excited delirium.’ ” The letter was in response to a proposed rule to register emergency medical services agencies under the Protecting Patient Access to Emergency Medications Act of 2017. The rule would allow EMTs to deliver controlled substances to patients.

“We urge that if this rule is finalized, mechanisms, such as an annual report, are implemented to track and monitor the use of certain controlled substances, including ketamine and other sedating medications,” Levin wrote. “Specifically, the standing orders established in all jurisdictions must include clear, evidence-based protocols for the administration of the permitted controlled substances, and any exceptions to such protocols must require review and approval through a verbal or other direct order for the particular situation from a supervising physician. The protocols should allow use of these medications only for treatment purposes in medically appropriate situations and should explicitly bar their use to achieve incapacitation solely for law enforcement purposes.” ■