AMA: 'Excited Delirium' Not a Legitimate Medical Diagnosis

Marcia Frellick

June 14, 2021

Current evidence does not support use of "excited delirium" or "excited delirium syndrome" as a medical diagnosis, the American Medical Association (AMA) said today, and the term should not be used unless clear diagnostic criteria are validated.

The term is disproportionately applied to people of color, "for whom inappropriate and excessive pharmacotherapy continues to be the norm instead of behavioral de-escalation," language in the report by the AMA's Council on Science and Public Health (CSAPH) stated, and is therefore indicative of systemic racism.

That conclusion was one of many included in CSAPH Report 2, which was adopted today at the special meeting of the AMA House of Delegates.

The AMA also opposes "use of sedative/hypnotic and dissociative agents, including ketamine, as a pharmacologic intervention for agitated individuals in the out-of-hospital setting, when done solely for a law enforcement purpose."

Medications typically used for restraint include dissociative ketamine, benzodiazepine sedatives such as midazolam, and antipsychotic medications including olanzapine or haloperidol, alone or in combination.

Kenneth Certa, MD, from the American Psychiatric Association, speaking on behalf of the section council on psychiatry, said in a reference committee hearing: "We have been very concerned over the years with the development of the inexact diagnosis of 'agitated delirium' or 'excited delirium,' especially after having had a number of individuals, more than what's reported in the press, die by the use of ketamine in the field for this inexact diagnosis."

Tamaan Osbourne-Roberts, MD, a delegate and CSAPH member, said the diagnosis lacks scientific evidence and is "disproportionately applied to otherwise healthy Black men in their mid-30s and these men are most likely to die from resulting first-responder actions."

Osbourne-Roberts testified that de-escalation training should be more widely used and that crisis intervention team models in which behavioral health specialists are first deployed to respond to behavioral health emergencies should be more prevalent.

Andrew Rudawsky, MD, an assistant medical director of two emergency departments and delegate from Ohio, speaking as an individual, testified: "I can tell you from first-hand experience that 'excited delirium' is very real. These acutely ill, unstable patients have an emergency medical condition best cared for by an emergency medicine physician."

The report recognizes that drugs used outside a hospital setting by nonphysicians come with significant risks, particularly for those with underlying conditions and in terms of drug–drug interactions.

I completely agree that medicine should not be practiced by law enforcement.

"I completely agree that medicine should not be practiced by law enforcement," Rudawsky said. "I'm gravely concerned by the legal ramifications of stating that this condition doesn't exist."

He said he is optimistic that the Diagnostic and Statistical Manual of Mental Disorders (DSM) will be updated to include "excited delirium."

The report urges that medical and behavioral health specialists, instead of law enforcement, serve as first responders and decision-makers in medical and mental health emergencies in local communities.

Additionally, the report urges that "administration of any pharmacologic treatments in the out-of-hospital setting be done equitably, in an evidence-based, antiracist, and stigma-free way."

The report calls on law enforcement and frontline emergency medical service personnel, who are a part of the "dual response" in emergency situations, to engage in training overseen by EMS medical directors. "The training should minimally include de-escalation techniques and the appropriate use of pharmacologic intervention for agitated individuals in the out-of-hospital setting," the report states.

Recommendation on Oversight Draws Controversy

Several commenters were emergency physicians and medical directors who expressed concern that investigation of potential cases of inappropriate pharmacologic intervention would be overseen by nonphysicians.

The CSAPH authors write that independent investigators are appropriate, whereas those in emergency medicine say EMS medical directors should lead oversight.

Stephen Epstein, MD, chair of the section council on emergency medicine, speaking on behalf of the section council, had moved for referral of the portion of the report that deals with oversight of EMS.

"We're concerned that recommendation 6, by calling for independent investigators, would put nonphysicians in the position of supervising the practice of medicine of a board-approved specialty. This would set an unfortunate precedent for our AMA," he said.

Epstein also said the American College of Emergency Physicians will soon release a report on "excited delirium," which will add key information for debating the issue.

He added that a new report on the safety of ketamine in out-of-hospital use was published just last week in the Annals of Emergency Medicine. The authors reviewed more than 11,000 cases of the pharmacologic intervention over the past 2 years.

"We believe this information may add substantively to the recommendation in this report," Epstein said.

Recommendation 6 was referred to the AMA Board for a decision, but the rest of the report was overwhelmingly adopted.

Certa, Osbourne-Roberts, Rudawsky, and Epstein have reported no relevant financial relationships.

Marcia Frellick is a freelance journalist based in Chicago. She has previously written for the Chicago Tribune, Science News, and, and was an editor at the Chicago Sun-Times, the Cincinnati Enquirer, and the St. Cloud (Minnesota) Times. Follow her on Twitter at @mfrellick

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