‘Excited Delirium’ Reflects System of Control, Not Care for MH Crises

Last October, Gov. Gavin Newsom signed legislation that made California the first state to ban the use of the term “excited delirium” as a cause of death.

The law, which prohibits reference to the controversial term on death certificates and autopsy reports and in civil litigation, builds on prior momentum in moving away from the use of “excited delirium.” In March last year, the National Association of Medical Examiners (NAME) approved a position statement asserting that NAME does not endorse the terms “excited delirium” and “excited delirium syndrome” as a cause of death.

In 2020, APA approved a position statement asserting that “[t]he term ‘excited delirium’ is too non-specific to meaningfully describe and convey information about a person. ‘Excited delirium’ should not be used until a clear set of diagnostic criteria are validated.” And the following year the AMA House of Delegates approved a resolution stating that “current evidence does not support ‘excited delirium’ or ‘excited delirium syndrome’ as a medical diagnosis, and [the AMA] opposes the use of the terms until a clear set of diagnostic criteria are validated.”

Taking seriously the critique of “excited delirium” put forth by these groups means moving past semantic debates and embracing changes in how medical and law enforcement professionals respond to, and care for, individuals who are experiencing crisis.

“Excited delirium” is a contested term that has been used to describe individuals who exhibit extreme or bizarre behavior, typically in conjunction with the use of narcotics. A large percentage of cases labeled as “excited delirium” result in death, with mortality rates between 8.3% and 16.5% depending on setting and context. Forensic pathologist Charles Wetli, M.D., invented the term in 1985, theorizing that a series of deaths of Black female sex workers were the result of spontaneous lethal reactions to cocaine and sex and that the deaths of men who appeared to have used cocaine prior to fatal encounters with law enforcement were the result of a comparable spontaneous reaction. Although a serial killer was eventually convicted for the deaths of the women, Wetli did not abandon the term.

In the ensuing 38 years, “excited delirium” has frequently been used by law enforcement officers to refer to highly agitated individuals, by coroners or medical examiners as an official cause of death, and by some medical professionals in emergency room settings. There are few explicit definitions for “excited delirium,” and it is used differently in different settings. As a cause of death, the term has come under closer scrutiny because a disproportionate number of the people to whom “excited delirium” is attributed are Black men who died during or following interactions with police; attributing deaths to “excited delirium” can sometimes mean that the incident is not classified as a homicide and is therefore not investigated. The possibility that “excited delirium” may obscure police responsibility for deaths has greatly concerned surviving family members and medical professionals alike.

Psychiatrists Can Help Clarify Debate

The new California law and the guidance from NAME to cease using “excited delirium” as a cause of death are welcome news for advocates who have seen little meaningful policy reform, despite growing public awareness of the racist history of “excited delirium” following the deaths of Elijah McClain and George Floyd.

In personal correspondence with the authors of this article, Altaf Saadi, M.D., an assistant professor of neurology at Harvard Medical School and an “asylum evaluator” with Physicians for Human Rights, said that “medical associations and professionals should reject not only the term ‘excited delirium,’ but the concept as a whole.” From Saadi’s perspective, abandoning the term is the first step, but it must be followed by “investment in alternative models of crisis response … utilizing law enforcement as a last resort.”

Mental health professionals have an important role to play in this debate because proponents of the term attribute the “condition” to some combination of neurological and psychological factors. While DSM-V-TR does recognize several forms of delirium as a condition with distinct criteria, APA is clear in its position statement that those criteria do not match the symptoms attributed to individuals who have been described as suffering from “excited delirium.”

However, some disagreement persists. The American College of Emergency Physicians used the term “excited delirium” in the past but replaced it with “hyperactive delirium with severe agitation” in a 2021 report. The International Association of Chiefs of Police recognizes “excited delirium” as a medical emergency with real clinical concerns. And the Minneapolis Police Department, in defense of its officers in the federal trial for the death of George Floyd, stated that its officers were simply following training videos on how to deal with individuals displaying characteristics of “excited delirium.” The department has recently dropped the terminology “excited delirium” from its curriculum, replacing it with “severe agitation with confusion.”

Better data are needed on the circumstances in which the term “excited delirium” is applied to individuals and the outcome of those events. In its position statement, APA called for just such a data-tracking effort and an analysis of any disparate impacts on Black communities, people living with mental illness, and other structurally marginalized populations. Unfortunately, the effort to collect needed data related to “excited delirium” is undermined by the lack of coherent systems for tracking officer-involved deaths.

We Need Caring, Not Control

Ultimately, the term “excited delirium” is symptomatic of a system that confronts people who are in crisis with commands for control, rather than compassion and care. What is needed are alternatives to policing when individuals are experiencing psychological or behavioral health crises. In 1989 Eugene, Ore., launched CAHOOTS (Crisis Assistance Helping Out On The Streets), an innovative community-based public safety system to provide a mental health–first response for crises involving mental illness, homelessness, and addiction. The program has been replicated in Arizona and Colorado. Local efforts in every area of the nation would benefit from involvement by psychiatrists and mental health professionals.

APA and many other organizations support the creation of such systems of care for those in crisis, particularly as part of the planned expansion of 988 crisis services.

The one-time investments from the 2021 American Rescue Plan, which includes billions of dollars for mental health and substance use disorder services, are an important down payment in funding the sorts of services needed, but will require additional, and continuous, investments by federal, state, and local governments. The Biden Mental Health Plan seeks to build more behavioral health clinics across communities to offer 24/7 care for people in mental health and drug crises. Lawmakers need to hear from mental health professionals about the importance of these investments and specifically need to understand that such services are crucial to supporting patients recovering from crisis. ■