Structural determinants of police responses to psychotic crises: a narrative review with implications for Brazil

Determinantes estruturais das respostas policiais a crises psicóticas: uma revisão narrativa com implicações para o Brasil

Determinantes estructurales de las respuestas policiales ante crisis psicóticas: una revisión narrativa con implicaciones para Brasil

1. César Augusto Trinta Weber

Affiliation of authors:

1 [Faculdade de Medicina, Universidade Luterana do Brasil, Canoas, RS, Brasil. Faculdade Paulista de Ciências da Saúde, São Paulo, SP, Brasil]

2 [Faculdade Paulista de Ciências da Saúde, São Paulo, SP, Brasil; Associação Brasileira de Psiquiatria, Rio de Janeiro, RJ, Brasil]

Chief Editor responsible for the article: Leandro Fernandes Malloy-Diniz

Authors contributions according to the Taxonomia CRediT: Weber CAT, da Silva AG [1, 10, 13, 14].

Disclosure of potential conflicts of interest: none

Funding: none

Approval Research Ethics Committee (REC): not applicable

Received on: 2026/06/25 | Accepted on: 2026/06/29 | Published on: 2026/06/29

How to cite: Weber CAT, da Silva AG. Structural determinants of police responses to psychotic crises: a narrative review with implications for Brazil. Debates Psiquiatr. 2026;16:1-24, e1630. https://doi.org/10.25118/2763-9037.2026.v16.1630

Abstract

Introduction: Police interventions involving individuals experiencing psychotic crises have raised increasing concern due to the risk of escalation and fatal outcomes. These events highlight structural gaps in the coordination between public security and mental health systems, particularly in contexts where police act as first responders to clinical emergencies. Objective: To synthesize evidence on police responses to psychotic crises, with emphasis on structural determinants, stigma, co-response models, and prevention strategies. Methods: This narrative review was prepared according to the SANRA (Scale for the Assessment of Narrative Review Articles) recommendations to improve methodological transparency and reporting. It was included studies published between 2005 and 2025, identified through searches in PubMed/MEDLINE, Scopus, Web of Science, PsycINFO, and SciELO, complemented by Google Scholar and institutional reports. Eligible publications addressed police interactions in psychotic crises and included empirical studies, reviews, and guidelines. A structured selection process was applied, and findings were analyzed using thematic synthesis. Results: A total of 25 publications were included. Four main themes emerged: (A) lack of police preparedness; (B) failures in risk management; (C) symptomatic aggression is not a crime; and (D) state responsibility and prevention strategies. Evidence indicates that inadequate training, absence of structured risk-assessment protocols, and stigmatizing perceptions contribute to escalation and inappropriate use of force. In contrast, co-response models, continuous training, and integration with community mental health services are associated with improved outcomes. Conclusion: Police-related deaths during psychotic crises are influenced by structural factors rather than isolated decisions. Strengthening integrated crisis-response systems, including collaboration between public security and healthcare services, may contribute to safer and more effective management of psychiatric emergencies.

Palavras-chave: psychotic disorders, mental health services, police, violence, crisis intervention, risk assessment.

Resumo

Introdução: As intervenções policiais envolvendo indivíduos em crise psicótica têm suscitado crescente preocupação devido ao risco de escalonamento dos conflitos e de desfechos fatais. Esses eventos evidenciam lacunas estruturais na articulação entre os sistemas de segurança pública e de saúde mental, particularmente em contextos nos quais a polícia atua como primeira resposta a emergências clínicas. Objetivo: Sintetizar as evidências sobre as respostas policiais às crises psicóticas, com ênfase nos determinantes estruturais, no estigma, nos modelos de coparticipação entre polícia e profissionais de saúde (co-response) e nas estratégias de prevenção. Métodos: Esta revisão narrativa foi elaborada de acordo com as recomendações da SANRA (Scale for the Assessment of Narrative Review Articles) para melhorar a transparência metodológica e o relato. Incluiu estudos publicados entre 2005 e 2025, identificados por meio de buscas nas bases PubMed/MEDLINE, Scopus, Web of Science, PsycINFO e SciELO, complementadas por pesquisas no Google Scholar e por relatórios institucionais. Foram elegíveis publicações que abordassem interações policiais em situações de crise psicótica, incluindo estudos empíricos, revisões e diretrizes. Aplicou-se um processo estruturado de seleção, e os achados foram analisados por meio de síntese temática. Resultados: Foram incluídas 25 publicações. Emergiram quatro temas principais: (A) insuficiente preparo policial; (B) falhas no manejo do risco; (C) agressividade sintomática não constitui crime; e (D) responsabilidade do Estado e estratégias de prevenção. As evidências indicam que treinamento inadequado, ausência de protocolos estruturados de avaliação de risco e percepções estigmatizantes contribuem para o escalonamento das ocorrências e para o uso inadequado da força. Em contrapartida, modelos de resposta integrada (co-response), capacitação contínua e integração com serviços comunitários de saúde mental estão associados a melhores desfechos. Conclusão: As mortes relacionadas à atuação policial durante crises psicóticas são influenciadas por fatores estruturais, mais do que por decisões isoladas. O fortalecimento de sistemas integrados de resposta a crises, incluindo a colaboração entre os serviços de segurança pública e de saúde, pode contribuir para um manejo mais seguro e eficaz das emergências psiquiátricas.

Palavras-chave: transtornos psicóticos, serviços de saúde mental, polícia, violência, intervenção em crise, avaliação de risco

Resumen

Introducción: Las intervenciones policiales que involucran a personas en crisis psi cótica han generado una preocupación creciente debido al riesgo de escalada de los incidentes y de desenlaces fatales. Estos eventos ponen de manifiesto deficiencias estructurales en la coordinación entre los sistemas de seguridad pública y salud mental, particularmente en contextos donde la policía actúa como primer interviniente ante emergencias clínicas. Objetivo: Sintetizar la evidencia sobre las respuestas policiales ante crisis psicóticas, con énfasis en los determinantes estructurales, el estigma, los modelos de respuesta conjunta (co-response) y las estrategias de prevención. Métodos: Esta revisión narrativa se elaboró siguiendo las recomendaciones de la SANRA (Escala para la Evaluación de Artículos de Revisión Narrativa) con el fin de mejorar la transparencia metodológica y la calidad de la presentación de la información. Incluyó estudios publicados entre 2005 y 2025, identificados mediante búsquedas en PubMed/MEDLINE, Scopus, Web of Science, PsycINFO y SciELO, complementadas con Google Scholar e informes institucionales. Se incluyeron publicaciones que abordaran las interacciones policiales en situaciones de crisis psicótica, incluyendo estudios empíricos, revisiones y guías. Se aplicó un proceso estructurado de selección y los hallazgos fueron analizados mediante síntesis temática. Resultados: Se incluyeron 25 publicaciones. Emergieron cuatro temas principales: (A) insuficiente preparación policial; (B) fallas en la gestión del riesgo; (C) la agresividad sintomática no constituye un delito; y (D) responsabilidad del Estado y estrategias de prevención. La evidencia indica que la capacitación insuficiente, la ausencia de protocolos estructurados de evaluación del riesgo y las percepciones estigmatizantes contribuyen a la escalada de los incidentes y al uso inapropiado de la fuerza. Por el contrario, los modelos de respuesta conjunta (co-response), la capacitación continua y la integración con los servicios comunitarios de salud mental se asocian con mejores resultados. Conclusión: Las muertes relacionadas con la actuación policial durante crisis psicóticas están influidas por factores estructurales más que por decisiones aisladas. El fortalecimiento de sistemas integrados de respuesta a crisis, incluyendo la colaboración entre los servicios de seguridad pública y de salud, puede contribuir a una gestión más segura y eficaz de las emergencias psiquiátricas.

Palabras clave: trastornos psicóticos, servicios de salud mental, policía, violencia, intervención en crisis, evaluación del riesgo.

Introduction

Recent reports of police interventions with fatal outcomes involving individuals experiencing psychotic crises have been documented in Brazil and other countries, drawing attention to persistent challenges in the coordination between public security and mental health systems. Although psychiatric crises are primarily clinical events, studies suggest that the absence of specialized protocols and the predominance of force-centered approaches are associated with a higher risk of adverse outcomes, including fatalities.

Psychotic crises are complex situations characterized by severe alterations in perception, thought, and behavior, often requiring immediate clinical attention. In many contexts, however, police officers are the first responders to such situations, particularly when crises occur in public spaces or are perceived as threats to safety. When mental health services are not readily available or integrated with emergency response systems, police intervention may become the default institutional response.

This dynamic creates a critical interface between public security and healthcare systems. Without adequate training, clear operational protocols, and coordinated crisis-response models, encounters between police officers and individuals experiencing severe mental distress may escalate rapidly. International literature has increasingly examined how institutional factors, such as training structures, risk-assessment practices, stigma related to mental illness, and the availability of community mental health services, influence the outcomes of these encounters.

Understanding these structural dimensions is particularly relevant in the Brazilian context, where the Psychosocial Care Network ( Rede de Atenção Psicossocial – RAPS ) has expanded access to community-based mental health services but where coordination with public security institutions remains limited and insufficiently studied.

Given the multidimensional nature of these events, integrating evidence from clinical research, public security studies, and policy analyses is essential for understanding how institutional structures shape crisis outcomes. This article presents a narrative review of structural factors associated with lethal police responses during psychotic crises and identifies evidence that may inform improvements in crisis management and public policy.

Objective

To synthesize evidence on police responses to psychotic crises, with emphasis on structural determinants, stigma, co-response models, and prevention strategies.

Methods

Type of study

This study was conducted as a narrative review aimed at critically integrating heterogeneous bodies of literature addressing police responses to psychotic and other severe mental health crises. Narrative reviews are particularly suitable for examining complex phenomena involving multiple institutional, clinical, and social dimensions, allowing the integration of evidence derived from studies with diverse methodological designs. In this approach, emphasis is placed on conceptual coherence and convergence of findings rather than on the quantitative aggregation of results. As a narrative review, the objective was not to exhaustively identify all available studies but rather to synthesize conceptually relevant literature across different methodological traditions. This narrative review was prepared according to the SANRA (Scale for the Assessment of Narrative Review Articles) recommendations to improve methodological transparency and reporting.

Search strategy and time frame

The literature search was conducted in November 2025 and included publications from the last two decades (2005–2025). Searches were performed in major bibliographic databases relevant to health, social sciences, and public policy research, including PubMed/MEDLINE, Scopus, Web of Science, PsycINFO, and SciELO. Additional sources were identified through Google Scholar as a supplementary search tool, as well as through technical documents and institutional reports published by organizations involved in mental health policy and policing practices.

These sources included the World Health Organization (WHO), the Pan American Health Organization (PAHO), NHS England, the College of Policing (United Kingdom), the UK Home Office, and the Brazilian Ministries of Health and Justice.

Search terms were applied in Portuguese, English, and Spanish and included combinations of descriptors such as psychotic crisis, mental health crisis, police response, use of force, co-response, Crisis Intervention Team, psychiatric emergency, risk assessment, violence, public security, and Brazil. These descriptors were combined and adapted according to the indexing systems of each database when appropriate.

The search strategy was designed to identify relevant academic and institutional literature addressing police responses to mental health crises across different contexts. As this study follows a narrative review design, the search aimed to provide a structured overview of the available literature rather than to achieve exhaustive systematic coverage of all publications on the topic.

Eligibility criteria

Studies were considered eligible if they met the following criteria: (1) addressed police interventions involving individuals experiencing psychotic crises; interventions in situations involving psychotic crises or psychotic crises; (2) presented empirical data, qualitative analyses, systematic reviews, implementation studies, technical reports, or institutional guidelines; (3) were published between 2005 and 2025; (4) were written in Portuguese, English, or Spanish; and (5) demonstrated direct relevance to at least one of the four analytical axes defined for this review: police training and professional competencies; risk assessment and crisis management; distinction between symptomatic aggression and criminal behavior; and public policies and prevention strategies.

Studies were excluded if they consisted solely of opinion pieces or editorials without methodological grounding; if they focused exclusively on forensic psychiatry without an interface with psychiatric crisis situations; if they addressed psychopathy, serial offenders, or premeditated violence; if they focused on non-psychotic mental disorders (such as borderline personality disorder or isolated substance dependence) without addressing interactions with psychosis; if they were duplicates or lacked full-text availability; or if the primary population studied did not involve police interaction with individuals experiencing mental health crises.

Study selection process

The selection of studies followed a structured process designed to identify publications relevant to the objectives of the review. Initially, titles and abstracts were screened to identify potentially relevant publications. Articles considered pertinent at this stage were subsequently evaluated through full-text reading in order to determine their eligibility according to the predefined inclusion and exclusion criteria. Information from the selected studies was then extracted and organized for thematic analysis.

Data synthesis and analysis

Given the heterogeneous nature of the literature identified, including qualitative and quantitative studies, systematic reviews, implementation research, and governmental guidelines, an iterative thematic analysis was employed. This approach enabled the identification of recurring themes and analytical categories across studies with different methodological traditions.

The findings were organized into thematic categories corresponding to the analytical axes of the review, which are presented and discussed in the Results section. The synthesis integrated evidence from different methodological approaches and from both international and Brazilian contexts while maintaining analytical rigor and conceptual coherence. Accordingly, the identification, selection, and interpretation of the evidence were guided by thematic relevance and conceptual contribution rather than by the exhaustive procedures typically required in systematic reviews.

Results and Discussion

A total of 25 publications (including empirical studies, systematic reviews, and institutional reports) met the eligibility criteria and were included in the narrative synthesis of this review. These studies comprised a heterogeneous body of literature, including observational studies, program evaluations, systematic reviews, policy analyses, implementation studies, and governmental reports addressing police responses to mental health crises.

Table 1 presents the main characteristics of the studies included in the review, providing an overview of their geographical origin, methodological design, thematic focus, and principal contributions to the understanding of police responses to psychotic crises.

The 25 included publications comprised empirical studies, systematic and narrative reviews, program evaluations, implementation studies, governmental reports, and policy analyses. Most evidence originated from the United States, Canada, the United Kingdom, and Australia, whereas Brazilian studies were comparatively scarce. The literature addressed multiple dimensions of police responses to psychotic crises, including training models, risk assessment practices, stigma related to mental illness, co-response interventions, and mental health service organization.

Through thematic synthesis, four recurrent analytical domains emerged across the included studies: (A) lack of police preparedness; (B) failures in risk management; (C) symptomatic aggression is not a crime; and (D) state responsibility and prevention strategies. These domains provided the conceptual framework for organizing the findings and discussing the structural determinants associated with police responses to psychotic crises.

These categories synthesize the principal empirical and conceptual contributions identified across the included studies and represent recurring patterns in the literature on police encounters with individuals experiencing psychotic crises. A synthesis of these thematic categories and their main findings is presented in Table 2.

A. Lack of preparedness of police forces

Police action has traditionally been guided by operational doctrines emphasizing containment, neutralization, and the progressive use of force. However, psychotic crises require an approach that differs fundamentally from conventional policing tactics. Effective management of psychotic crises depends on de-escalatory communication, recognition of illness-derived behaviors, maintenance of safe distance, and activation of specialized or multidisciplinary teams.

The literature consistently indicates that when police officers without specific training in mental health act as first responders in psychiatric crises, encounters tend to become operationally more complex and more prone to escalation. In these situations, officers may have difficulty distinguishing between behaviors arising from psychotic symptoms and behaviors reflecting intentional aggression. As a result, symptomatic agitation may be interpreted as immediate dangerousness. The absence of appropriate training therefore compromises not only the safety of individuals experiencing a crisis but also the safety of responding officers .

Across multiple countries, lack of specialized training has been identified as one of the principal predictors of lethal outcomes during police encounters involving individuals with severe mental disorders. Programs based on Crisis Intervention Team (CIT) models have demonstrated that structured training programs can reduce the use of force while increasing referrals to mental health services, particularly when these programs operate within integrated community response systems . These findings suggest that training deficits should not be interpreted merely as organizational limitations but as structural factors that can directly influence operational decisions and potentially lethal outcomes.

Another important issue highlighted in the literature is the limited number of empirical studies examining how police officers interpret psychotic behaviors during crisis encounters and how those interpretations influence the decision to use force. Existing evidence points to significant gaps in police education regarding mental health, including insufficient training in symptom recognition, crisis negotiation, and de-escalation techniques. Reviews of police training curricula and public security policies indicate that systematic instruction on psychotic crises is often absent or fragmented. This educational insufficiency suggests that responses based primarily on physical containment or coercive intervention may partly reflect a lack of technical preparation. In addition, institutionalized stigma toward mental disorders contributes to the perception that psychotic episodes are inherently dangerous, regardless of contextual factors, reinforcing distorted risk assessments .

Recent research suggests that unpreparedness in responding to psychiatric crises is not limited to technical or procedural factors but also involves cognitive and affective dimensions. A study conducted in 2025 found that implicit biases, measured through automatic association tests, interact with organizational climate and influence decision-making during crisis encounters. Officers with stronger implicit associations between mental illness and dangerousness were less likely to refer individuals to health services and more likely to adopt punitive or avoidant responses. These findings indicate that effective crisis-response strategies must address both procedural training and cognitive processes such as bias awareness and emotional regulation .

Evidence further indicates that continuous training programs are substantially more effective than isolated training sessions. Implementation studies have demonstrated that brief, recurrent training modules combined with realistic scenario simulations significantly improve officers’ abilities to recognize psychotic symptoms, modulate vocal tone, maintain safe interpersonal distance, and apply verbal de-escalation strategies. These findings suggest that improving responses to psychiatric crises requires not only the inclusion of mental health topics in basic police training but also the development of permanent continuing education systems within public security institutions.

B. Failures in risk management

Psychotic episodes are widely described in the clinical literature as states of heightened vulnerability that differ fundamentally from deliberate criminal behavior. When crisis situations are interpreted primarily through a criminal framework, treating the individual as an attacker rather than as a patient, this often reflects failures in risk assessment protocols and operational decision-making.

Robust risk management in psychotic crises requires structured assessment procedures that incorporate clinical, environmental, and situational information. Effective crisis management typically includes environmental assessment, attempts to isolate the scene, the allocation of time for negotiation, the presence of trained mediators, and the use of minimal and proportional force.

Structured approaches to risk assessment have demonstrated important advantages in crisis contexts. Models based on Structured Professional Judgment (SPJ) combine standardized criteria with professional evaluation and have been shown to reduce precipitous decisions and impulsive use of force by encouraging systematic analysis of risk factors and protective factors . Despite their potential benefits, the incorporation of structured risk assessment tools into routine public security practices in Brazil remains limited and insufficiently documented.

Response time is another central element in risk management. Rapid interventions carried out without preliminary information gathering or situational analysis increase the probability of escalation. In this sense, crisis management can also be understood as a form of time management: allowing time for observation, negotiation, and de-escalation often reduces the need for coercive intervention. Nevertheless, this temporal dimension is rarely incorporated into operational protocols.

Decision-making in crisis situations is also strongly influenced by officers’ own emotional states. Acute stress, anticipatory fear, and perceptions of unpredictability have been identified as significant predictors of violent decision-making. When officers lack institutional psychological support or training in emotional regulation strategies, disorganized or erratic behaviors may be interpreted as more threatening than they actually are, increasing the likelihood of escalation .

Several countries have attempted to address these challenges through police–mental health co-response models, in which mental health professionals participate directly in crisis calls alongside or in place of police officers. Empirical studies have reported reductions of up to 16.5% in involuntary psychiatric detentions in jurisdictions where such models have been implemented . International reviews also indicate that co-response teams improve referral pathways to treatment while reducing response times and unnecessary use of force . Some experts argue that these teams should be led by unarmed clinicians, who are better equipped to address psychiatric crises through therapeutic rather than coercive interventions . In Brazil, however, the implementation of co-response approaches remains limited and poorly documented, with crisis responses still predominantly centered on police intervention.

C. Symptomatic aggression is not a crime

Understanding the nature of aggression in psychotic conditions is essential for interpreting crisis encounters appropriately. In many cases, aggressive behavior associated with psychosis is involuntary, disorganized, and directed primarily toward the individual’s internal experience rather than toward other people. The specialized literature consistently describes dangerousness in psychosis as the exception rather than the rule.

A growing body of research challenges the widely held assumption that psychotic disorders are strongly associated with violence. Contemporary studies indicate that most aggressive behaviors attributed to individuals with severe mental disorders are more strongly associated with social determinants, such as poverty, lack of access to treatment, and substance use, than with psychotic symptoms themselves .

These findings suggest that the automatic interpretation of psychosis as a generalized threat lacks consistent empirical support. Nevertheless, police practice frequently treats disorganized or agitated behaviors as direct indicators of imminent violence. Such interpretations may lead to rapid escalation of force in situations where clinical intervention would be more appropriate.

The indiscriminate association between mental illness and violence also contributes to the persistence of social stigma. Observational studies have shown that stigmatizing beliefs about mental disorders are associated with stronger support for coercive institutional responses. In particular, beliefs linking schizophrenia with dangerousness have been associated with greater acceptance of lethal force in hypothetical crisis scenarios . These findings indicate that the challenge extends beyond gaps in clinical knowledge to include deeply rooted cultural and institutional prejudices.

Hostile behavior directed intentionally toward others generally involves elements such as planning, coherent reality testing, and deliberate motivation, characteristics that are typically absent during severe psychotic crises. Empirical studies indicate that most aggressive behaviors observed in schizophrenia are impulsive, reactive, and non-premeditated. These behaviors are frequently triggered by threatening hallucinations or persecutory delusions rather than by intentional efforts to harm others .

D. State responsibility and prevention strategies

Several authors emphasize that analysis of lethal outcomes during psychiatric crises should not focus exclusively on individual decisions made by police officers. Instead, these events must be examined within a broader systemic framework that includes institutional policies, training structures, and the design of crisis-response systems.

Structural solutions proposed in the literature include the development of police–mental health co-response protocols, the creation of specialized mobile crisis teams, mandatory and continuous training in de-escalation techniques, strengthening of community-based mental health services, and policy reforms that reduce the centrality of police intervention in situations that are fundamentally related to health care needs .

Among these strategies, co-response models have shown particularly consistent results in reducing the use of force and fatal outcomes. Studies indicate that the presence of mental health professionals during crisis encounters not only improves patient outcomes but also enhances officer safety by reducing uncertainty and facilitating clinical decision-making .

Strengthening community-based mental health networks also plays a crucial preventive role. In Brazil, the Psychosocial Care Network (RAPS) provides community services designed to support individuals with severe mental disorders through territorial care. Regions with greater availability of CAPS III services and mobile crisis teams have reported fewer severe crises and lower rates of involuntary psychiatric hospitalization . When community mental health systems function effectively, many crises can be addressed earlier, reducing the likelihood that police intervention will be required.

Reconfiguration of institutional responsibilities may also contribute to improved crisis management. The Right Care, Right Person program implemented in the United Kingdom has redirected a substantial proportion of calls previously handled by police to specialized mental health services. Evaluations of this initiative indicate reductions in arrests, deaths, and response times for individuals experiencing psychiatric crises . Similar strategies could potentially be adapted to the Brazilian context.

The establishment of standardized national indicators to monitor police interventions in psychotic crises would enable the assessment of risk patterns, measure the impact of co-response programs, and guide public policies more effectively.

Effective public policies in this area require continuous monitoring and evaluation. Integrated data systems linking health services, public security institutions, and social assistance networks are essential for identifying patterns of crisis events, evaluating intervention outcomes, and guiding resource allocation. Without reliable data, responses to psychiatric crises tend to remain reactive and improvised rather than strategic and preventive.

A Table 3 summarizes evidence-based strategies that have been associated with reductions in lethal outcomes during psychotic crises.

Taken together, the evidence suggests that deaths occurring during psychotic episodes should not be interpreted as natural or inevitable phenomena. Instead, they may reflect how the State organizes its institutional responses to psychiatric crises. Fatal outcomes often arise in systems where public security, mental health services, and social policies operate with limited integration.

Preventing lethality therefore requires structural changes that include strong territorial care networks, specialized crisis-response teams, clearly defined operational protocols, and continuous professional training. Evidence from jurisdictions where such measures have been implemented indicates consistent improvements, including reductions in deaths, improved clinical outcomes, and greater institutional efficiency.

Deaths associated with police management of psychotic crises can be understood less as individual failures and more as outcomes of systems with low integration between public security, mental health, and social policies. Preventing lethality requires structural changes: strong territorial networks, specialized teams, clear protocols, and continuous training. Where these measures have been implemented, results are consistent, fewer deaths, better care, and greater institutional efficiency.

Ethical and legal challenges in police intervention during psychotic crises

Police interventions in psychotic crises involve significant ethical and legal dilemmas that extend beyond operational protocol implementation. The need to protect the life of the individual and others often conflicts with the use of force, individual liberty, and the right to mental health care.

Prioritizing coercive or punitive approaches may lead to human rights violations, particularly when individuals with severe disorders are treated as offenders rather than patients. Moreover, decisions made under high stress or unpredictable scenarios can result in civil or criminal liability for officers and institutions.

Legally, the lack of clear regulations on who should respond to psychiatric crises or the criteria for force use creates uncertainty for police officers and limits citizen protection. Structured risk assessment protocols and specialized training can mitigate these uncertainties, but gaps in regulation and oversight persist. The implementation of co-response models and integration with mental health services aims to mitigate such risks, providing more humane and safe responses ; however, effectiveness depends on legal clarity, institutional oversight, and adequate resources.

From an ethical standpoint, practices such as prolonged isolation, physical restraint, and the use of lethal force raise questions about proportionality, dignity, and necessity. Therefore, ethical and legal challenges reinforce the need for standardized national policies, clear protocols, and continuous monitoring to ensure that police interventions in psychotic crises are effective, safe, and compatible with fundamental rights.

Addressing these ethical and legal challenges requires the implementation of standardized national policies, clear operational protocols, and continuous monitoring to ensure safe, effective, and rights-compatible responses to psychotic crises.

Study limitations

This review has limitations inherent to the narrative method. The absence of a systematic protocol (e.g., PRISMA) may introduce selection bias, although an expanded and diversified search strategy was used. The heterogeneity of included studies, qualitative, quantitative, guidelines, meta-analyses, and trials, precludes direct comparisons and statistical synthesis. A substantial portion of the evidence originates from high-income countries, limiting generalizability to the Brazilian context, where the structure of RAPS, policing practices, and social inequalities have relevant specificities. Brazilian studies remain scarce and often qualitative, reducing the statistical robustness of national inferences. There is also a risk of publication bias, with greater visibility of fatal events than of successful interventions. Despite these limitations, convergence of national and international findings strengthens the consistency of the conclusions.

As this review followed a narrative synthesis approach consistent with narrative review methodology, a formal quality appraisal or risk-of-bias assessment of individual studies was not conducted. In addition, the thematic categorization of findings involves a degree of interpretative judgment, which may introduce some subjectivity despite efforts to maintain analytical rigor and conceptual coherence across the literature.

Conclusion

Fatal outcomes in psychotic crises involving police intervention predominantly reflect structural determinants, such as weaknesses in coordination between mental health and public safety systems, limitations in risk assessment practices, and gaps in the organization of community mental health services.

These findings indicate that such events are strongly shaped by how crisis response systems are structured, particularly when police act as first responders in mental health emergencies.

The strengthening of integrated crisis response models, combined with ongoing professional training and improved coordination between health and public safety sectors, represents a key strategy to reduce the escalation of psychotic crises and enhance safety for all individuals involved.

Future research should evaluate the implementation, feasibility, and effectiveness of these models across different institutional contexts, with particular emphasis on the Brazilian setting.