What Is the Pseudo-Psychiatric Term Excited Delirium?

In 2019, a 23-year-old, slightly built man went to an Aurora, Colorado convenience store to buy a drink. Elijah McClain was wearing a ski-type mask—an odd choice for August—and acting timidly.

On his way home, someone in the area, thinking he looked “sketchy,” called 911. An officer tried to stop him because he was “being suspicious” and, within seconds, made physical contact. Other officers arrived.

Mr. McClain tried to protest, citing his own awareness of his behavioral differences, saying: “I am an introvert. I’m going home.” One officer insisted he relax, otherwise, he would “change the situation.” As officers tried to move Mr. McClain off the street, it appeared to one of them that he reached for an officer’s weapon. All three officers took him to the ground and one applied a carotid-artery hold, cutting off blood flow to the brain.

On the ground, Mr. McClain, now frantic, again said, “I’m an introvert and I’m different.” His pleas continued as the officers talked with each other, acknowledging that Mr. McClain had acted suspiciously and then went for an officer’s gun. After a few minutes, Mr. McClain, unable to breathe easily, vomited several times. The officers, however, were mostly indifferent and one of them threatened to bring out his dog.

Eventually, an ambulance was called and the officers agreed among themselves that when the medics arrived they should give the suspect ketamine due to his “incredible strength.” Medics then injected Mr. McClain with 500 mg of ketamine—a very high dose for someone weighing 140 pounds—who then stopped breathing. He was kept alive but declared “brain dead” after three days. The medical examiner eventually listed the cause of death as “ketamine overdose.” No immediate action was taken against the police or paramedics although there were repercussions after Mr. McClain’s family filed a lawsuit.

In 2021, in Rochester, New York, Daniel Prude was visiting family when he became acutely psychotic. The police were called and found him wandering the streets, unarmed, naked, and not threatening anyone, Mr. Prude was restrained and a “spit-hood” was placed over his head. Unable to breathe, he died from lack of oxygen. His death was determined a homicide.

Then, in 2020, the world watched footage of George Floyd who died from excessive restraint on the street in Minneapolis. He had been pulled from his car, neither psychotic nor agitated. Already handcuffed, his contorted struggle to breathe was treated by police as resistance, who then used sustained pressure on the neck. This homicide was prosecuted.

Diagnosing a Pseudo-Psychiatric Disorder

What do the deaths of, Elijah McClain, Daniel Prude, and George Floyd have in common? First, no one should die from asphyxiation or medication overdoses when ordinary methods of arrest are available. Second, all three were Black men who died of injuries sustained in police custody.

Further, in all three cases, the term “excited delirium” was used by police as a reason to restrain them or to distance themselves from taking responsibility for the deaths. However, the “diagnosis” of excited delirium was not made by mental health professionals but by police and medical examiners.

In addition, in Mr. McClain’s case, the paramedics’ protocol permitted the use of ketamine by EMTs to subdue a citizen. Ketamine, a powerful anesthetic, should never be administrated outside a medically supervised setting. Two years after the incident, several officers and two paramedics were charged in Mr. McClain’s death. They pled not guilty and their trials are pending.

In Mr. Prude’s case, a lack of compassion coupled with a pseudo-diagnosis of excited delirium led to tragic consequences. While he did have phencyclidine (PCP) in his system, and excited delirium was noted as a factor, the actual cause of death was smothering. His cousin Dr. David Paul, a neurosurgeon, wrote in the New England Journal of Medicine:

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“We need a cultural shift to the expectation that deaths occurring at the hands of police are independently investigated. We need better collaboration between healthcare officials and police officers. And police need training in avoiding dangerous tactics such as spit hoods and excessive force when someone is already in handcuffs.”

Finally, in Mr. Floyd’s case, the criminal trial of Officer Derek Chauvin included a suggestion that the officer’s behavior could be justified due to the presence of excited delirium because there was evidence of cocaine in Mr. Floyd. That argument was not pursued.

How Does This Happen?

The sequence of events begins with police officers first being primed by 911 dispatchers; the EMTs are then briefed by police with their “diagnosis” of the problem; and then medical examiners end up using a term that is not a medical diagnosis.

In fact, both the American Medical Association and the American Psychiatric Association have condemned the use of the excited delirium label. In addition, the American College of Emergency Physicians and the American Society of Anesthesiologists have issued a joint warning that the use of ketamine—which has therapeutic value in other instances—must be medically supervised.

It may be that an autopsy diagnosis of excited delirium serves as an excuse to take the spotlight off highly problematic police interventions, instead of blaming mental illness or drugs. However, it is important to place accountability where it belongs. While there are dangerous citizens who may need containment, people with mental illness or behavioral differences (such as autism) require a different approach. Physical and chemical restraints—especially those with potential lethality—are not a one-size-fits-all technique.

De-escalation of Behavioral Crises Can Save Lives

Mental health professionals and law enforcement officials must collaborate, as Dr. Paul urged. Police are first responders to mental health crises and need more training. This includes recognizing situations, such as those involving Mr. McClain and Mr. Floyd, that did not start with a behavioral emergency. Rather than having 911 dispatchers and police "diagnosing” excited delirium, real-time access to—or even embedded mental health advice should be available.

Finally, medical examiners should not be a tool of law enforcement. Rather, they need the insight and courage to identify homicide when appropriate, as in these three cases. Mental health and law enforcement professionals must work together for the goals of humane handling of behavioral emergencies and avoiding excessive force in resolving them.

This post is by Kenneth J. Weiss, M.D., a member of the Arts and Humanities Committee at the Group for the Advancement of Psychiatry.