Current evidence does not support the 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 that clear diagnostic criteria are validated.

The term is disproportionately applied to people of color, “for whom inappropriate and excessive drug therapy continues to be the norm instead of behavioral de-escalation,” the Council on Science and Public Health (CSAPH) report said. ) of the AMA, and is therefore indicative of systemic racism.

This finding was one of many included in CSAPH 2 report, which was adopted today at the special meeting of the WADA House of Delegates.

The AMA also opposes “the use of sedative/hypnotic and dissociative agents, including ketamine, as pharmacological intervention for agitated individuals in an out-of-hospital setting, when performed only at law enforcement purposes”.

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

Kenneth Certa, MD, of the American Psychiatric Association, speaking on behalf of the Section Council on Psychiatry, told a referral committee hearing, “We have been very concerned over the years about the development of the inaccurate diagnosis of “excited delirium” or “excited delirium”, especially after killing a number of individuals, more than reported in the press, by the use of ketamine in the field for this inaccurate diagnosis .”

CSAPH delegate and member Tamaan Osbourne-Roberts, MD, said the diagnosis lacks scientific evidence and is “disproportionately applied to otherwise healthy black men in their mid-30s and that these men are most likely to die from the resulting actions of first responders.”

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

Andrew Rudawsky, MD, deputy medical director of two emergency departments and delegate from Ohio, speaking on a personal basis, testified, “I can tell you from first-hand experience that ‘excited delirium’ is very real. These critically ill and unstable patients have an emergency medical condition best treated by an emergency physician.”

The report acknowledges that drugs used outside of a hospital setting by non-physicians carry significant risks, particularly for those with underlying conditions and in terms of drug interactions.

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

“I absolutely agree that medicine should not be practiced by law enforcement,” Rudawsky said. “I am seriously concerned about the legal ramifications of claiming that this condition does not exist.”

He said he was optimistic that 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 “the administration of any pharmacological treatment outside of hospital should be done in an equitable, evidence-based, anti-racist and stigma-free manner.”

The report calls on law enforcement and frontline emergency medical service personnel, who are part of the ‘dual response’ in emergencies, to undergo training overseen by medical service medical directors emergency. “Training should at a minimum include de-escalation techniques and the appropriate use of pharmacological intervention for agitated individuals in the community setting,” the report states.

Supervision recommendation sparks controversy

Several commentators were emergency physicians and medical directors who feared that the investigation of potential cases of inappropriate pharmacological intervention would be overseen by non-physicians.

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

Stephen Epstein, MD, chair of the District Council on Emergency Medicine, speaking on behalf of the District Council, had requested the dismissal of the portion of the report that deals with EMS oversight.

“We are concerned that Recommendation 6, by calling for independent investigators, will place non-physicians in the position of overseeing the practice of medicine of a board-approved specialty. This would set an unfortunate precedent for our AMA,” did he declare.

Epstein also said the American College of Emergency Physicians will soon publish a report on “excited delirium”, which will add key information to debate the issue.

He added that a new report on the safety of ketamine in out-of-hospital use has been published no later than last week in Annals of Emergency Medicine. The authors reviewed over 11,000 cases of pharmacological intervention over the past 2 years.

“We believe this information can make a substantial contribution to the recommendation of this report,” Epstein said.

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

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

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

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