Tracing the Roots of Excited Delirium

Date: April 25, 2023 Reference: Walsh et al. Revisiting “Excited Delirium”: Does the Diagnosis Reflect and Promote Racial Bias? WJEM 2023 Dr. Brooks Walsh Guest Skeptic: Dr. Brooks Walsh is a former paramedic, and is currently an emergency physician in the Bridgeport Hospital, Yale-New Haven Health in Connecticut. This is an SGEM Xtra episode. Brooks reached out to me recently to see if we could revisit the issue of excited delirium. We had done a show on the topic five years ago on SGEM#218. At that time, we recognized there was no universally accepted definition of excited delirium. Please have a listen to the SGEM podcast to hear Brooks discuss the history of this issue and his recent publication. The American College of Emergency Physicians (ACEP) defined the term in 2009 as “acute delirium (not linked to dementia or preexisting pathologies) associated with extreme physical and psychomotor agitation”. The history of this issue goes back almost 200 years. Dr. Luther Bell described extreme agitation observed while he was the superintendent of the McLean Asylum for the Insane. The condition was named “Bell’s Mania” when published in the American Journal of Insanity (now American Journal of Psychiatry) in October, 1849 [1]. The term excited delirium syndrome (ExDS) was coined in the 1980s, after a flurry of deaths of individuals in custody or during arrests following extreme agitation [2]. ExDS usually involved men in their 30s after cocaine, methamphetamine, or ecstasy abuse [3-5]. Fast forward to 2008 when an ACEP resolution called for a group to study “excited delirium,” and to disseminate the paper to Emergency Medical Services (EMS) and law enforcement. The task force came up with a paper that was presented and accepted by the ACEP board in 2009. It was never published in a peer reviewed journal but it has been widely disseminated and cited. There is increasing awareness of the evidence that black men receive the diagnosis of ExDS more often than White men. Those black men who are labeled as having ExDS have a higher mortality than white men. Most recently, a report released by Physicians for Human Rights in March 2022 highlighted these concerns, attracting coverage from national new media. In emergency medicine, we try to be the physician who will treat anyone for anything at any time (hopefully without judgment). There has been an increased recognition of implicit and explicit biases in the house of medicine. This includes but is not limited to race, gender, age, and socioeconomic status. ACEP has made the equitable treatment of patients a priority, including recognition of the role that implicit bias exerts in EM [6]. A statement from ACEP described the death of George Floyd as a manifestation of a “public health emergency,” [7] and affirmed that “ACEP’s mission includes the promotion of health equity within the communities we serve.” Revisiting “Excited Delirium”: Does the Diagnosis Reflect and Promote Racial Bias? This brings us to the 2022 article called Revisiting "Excited Delirium": Does the Diagnosis Reflect and Promote Racial Bias? WJEM 2023 There were five key points raised in the article: Continuing lack of a clear definition for excited delirium Excited delirium is a health issue Excited delirium Is a health equity issue Racialized criteria for diagnosis “Just semantics?” Four actions were suggested in the article: Emergency medicine should avoid the concept of “excited delirium” Clinicians Should Use Established Medical Diagnoses ACEP Should “Retire” the 2009 Report Consider Greater Professional and Racial Diversity in Future Panels ACEP Task Force Report on Hyperactive Delirium with Severe Agitation in Emergency Settings 2021 ACEP published a task force report in April 2021 on Hyperactive Delirium with Severe Agitation in Emergency Settings. It said that “explicit discussion of ‘Excited Delirium Syndrome’ will only o...