Obesity in Severe Mental Illness: Antipsychotic-Associated Weight Gain and the Metabolic Monitoring That Does Not Happen
DOI:
https://doi.org/10.5281/zenodo.22260629Keywords:
Severe mental illness, Antipsychotic medication, Metabolic syndrome, Metabolic monitoring, Cardiometabolic riskAbstract
People with severe mental illness carry a substantially raised burden of obesity and metabolic syndrome, and antipsychotic
treatment contributes to it. Mean weight increase after starting antipsychotic treatment is reported at 4.85 kg, and metabolic
syndrome prevalence differs markedly between agents, from 47.2 per cent with clozapine to 19.4 per cent with aripiprazole. The
attribution is not simple. Meta-analysis reports metabolic syndrome in 20.2 per cent of unmedicated patients with schizophrenia,
and prevalence rises across illness stages from 10 per cent in drug-naive patients to 34.2 per cent in multi-episode patients, so
illness and circumstance contribute alongside medication. International guidance on metabolic monitoring has been consistent for
close to two decades and specifies weight, glucose, lipids and blood pressure. Audit repeatedly finds it incompletely performed.
This review sets out the measured prevalence, what the comparisons between agents and stages support, and the gap between
recommended and recorded monitoring.
References
Hjorthoj C, Sturup AE, McGrath JJ, Nordentoft M. "Years of potential life lost and life expectancy in schizophrenia: a systematic review and meta-analysis". Lancet Psychiatry 4(2017):295-301.
Laursen TM, Nordentoft M, Mortensen PB. "Excess early mortality in schizophrenia". Annu Rev Clin Psychol 10(2014):425-448.
Psychotropic medication review authors. "Impact of psychotropic medication effects on obesity and the metabolic syndrome in people with serious mental illness". Front Endocrinol 11(2020):573479.
De Hert M, Correll CU, Bobes J, Cetkovich-Bakmas M, Cohen D, Asai I, et al. "Physical illness in patients with severe mental disorders: prevalence, impact of medications and disparities in health care". World Psychiatry 10(2011):52-77.
Leucht S, Cipriani A, Spineli L, Mavridis D, Orey D, Richter F, et al. "Comparative efficacy and tolerability of 15 antipsychotic drugs in schizophrenia: a multiple-treatments meta-analysis". Lancet 382(2013):951-962.
Huhn M, Nikolakopoulou A, Schneider-Thoma J, Krause M, Samara M, Peter N, et al. "Comparative efficacy and tolerability of 32 oral antipsychotics for the acute treatment of adults with multi-episode schizophrenia: a systematic review and network meta-analysis". Lancet 394(2019):939-951.
Best Practice Advocacy Centre. "Monitoring for metabolic disorders in patients taking antipsychotic drugs". Best Practice Journal 3(2007):1-8.
De Hert M, Dekker JM, Wood D, Kahl KG, Holt RIG, Moller HJ. "Cardiovascular disease and diabetes in people with severe mental illness: position statement from the European Psychiatric Association, supported by the European Association for the Study of Diabetes and the European Society of Cardiology". Eur Psychiatry 24(2009):412-424.
National Clinical Audit of Psychosis. "National report for the early intervention in psychosis audit 2020/2021". Royal College of Psychiatrists, London (2021).
Vancampfort D, Stubbs B, Mitchell AJ, De Hert M, Wampers M, Ward PB, et al. "Risk of metabolic syndrome and its components in people with schizophrenia and related psychotic disorders, bipolar disorder and major depressive disorder: a systematic review and meta-analysis". World Psychiatry 14(2015):339-347.
Boer JN, Vinkers CH, Sommer IEC, Bakker PR. "Antipsychotic-induced weight gain: is the weight over? New guidelines needed". Acta Psychiatr Scand 146(2022):297-299.
Kahn RS, Fleischhacker WW, Boter H, Davidson M, Vergouwe Y, Keet IPM, et al. "Effectiveness of antipsychotic drugs in first-episode schizophrenia and schizophreniform disorder: an open randomised clinical trial". Lancet 371(2008):1085-1097.
Pillinger T, McCutcheon RA, Vano L, Mizuno Y, Arumuham A, Hindley G, et al. "Comparative effects of 18 antipsychotics on metabolic function in patients with schizophrenia, predictors of metabolic dysregulation, and association with psychopathology: a systematic review and network meta-analysis". Lancet Psychiatry 7(2020):64-77.
Rummel-Kluge C, Komossa K, Schwarz S, Hunger H, Schmid F, Lobos CA, et al. "Head-to-head comparisons of metabolic side effects of second generation antipsychotics in the treatment of schizophrenia: a systematic review and meta-analysis". Schizophr Res 123(2010):225-233.
Olanzapine metabolic investigators. "Weight gain and changes in metabolic variables following olanzapine treatment in schizophrenia and bipolar disorder". Clin Drug Investig 31(2011):455-482.
Mitchell AJ, Vancampfort D, Sweers K, van Winkel R, Yu W, De Hert M. "Prevalence of metabolic syndrome and metabolic abnormalities in schizophrenia and related disorders: a systematic review and meta-analysis". Schizophr Bull 39(2013):306-318.
Treatment-resistant schizophrenia investigators. "Metabolic problems among people with treatment-resistant schizophrenia are not unique to clozapine". Clin Schizophr Relat Psychoses (2025).
Vancampfort D, Wampers M, Mitchell AJ, Correll CU, De Herdt A, Probst M, et al. "A meta-analysis of cardio-metabolic abnormalities in drug naive, first-episode and multi-episode patients with schizophrenia versus general population controls". World Psychiatry 12(2013):240-250.
Holt RIG, Mitchell AJ. "Diabetes mellitus and severe mental illness: mechanisms and clinical implications". Nat Rev Endocrinol 11(2015):79-89.
Metabolic monitoring authors. "Metabolic monitoring for patients on antipsychotic medications". Psychiatric Times (2025).
Shiers DE, Rafi I, Cooper SJ, Holt RIG. "Positive cardiometabolic health resource: an intervention framework for patients with psychosis and schizophrenia, 2014 update". Royal College of Psychiatrists, London (2014).
Mitchell AJ, Delaffon V, Vancampfort D, Correll CU, De Hert M. "Guideline concordant monitoring of metabolic risk in people treated with antipsychotic medication: systematic review and meta-analysis of screening practices". Psychol Med 42(2012):125-147.
Barnes TRE, Paton C, Cavanagh MR, Hancock E, Taylor DM. "A UK audit of screening for the metabolic side effects of antipsychotics in community patients". Schizophr Bull 33(2007):1397-1403.
Allison DB, Mentore JL, Heo M, Chandler LP, Cappelleri JC, Infante MC, et al. "Antipsychotic-induced weight gain: a comprehensive research synthesis". Am J Psychiatry 156(1999):1686-1696.
Correll CU, Manu P, Olshanskiy V, Napolitano B, Kane JM, Malhotra AK. "Cardiometabolic risk of second-generation antipsychotic medications during first-time use in children and adolescents". JAMA 302(2009):1765-1773.
Firth J, Siddiqi N, Koyanagi A, Siskind D, Rosenbaum S, Galletly C, et al. "The Lancet Psychiatry Commission: a blueprint for protecting physical health in people with mental illness". Lancet Psychiatry 6(2019):675-712.
Siskind D, Hahn M, Correll CU, Fink-Jensen A, Russell AW, Bak N, et al. "Glucagon-like peptide-1 receptor agonists for antipsychotic-associated cardio-metabolic risk factors: a systematic review and individual participant data meta-analysis". Diabetes Obes Metab 21(2019):293-302.
Metformin guideline investigators. "Metformin for the prevention of antipsychotic-induced weight gain: guideline development and consensus validation". Schizophr Bull 51(2025):1193-1205.
Cooper SJ, Reynolds GP, Barnes TRE, England E, Haddad PM, Heald A, et al. "BAP guidelines on the management of weight gain, metabolic disturbances and cardiovascular risk associated with psychosis and antipsychotic drug treatment". J Psychopharmacol 30(2016):717-748.
Vancampfort D, Firth J, Correll CU, Solmi M, Siskind D, De Hert M, et al. "The impact of pharmacological and non-pharmacological interventions to improve physical health outcomes in people with schizophrenia: a meta-review of meta-analyses". World Psychiatry 18(2019):53-66.
Holt RIG, Gossage-Worrall R, Hind D, Bradburn MJ, McCrone P, Morris T, et al. "Structured lifestyle education for people with schizophrenia, schizoaffective disorder and first-episode psychosis (STEPWISE): randomised controlled trial". Br J Psychiatry 214(2019):63-73.
Osborn DPJ, Wright CA, Levy G, King MB, Deo R, Nazareth I. "Relative risk of diabetes, dyslipidaemia, hypertension and the metabolic syndrome in people with severe mental illnesses: systematic review and metaregression analysis". BMC Psychiatry 8(2008):84.
Ward M, Druss B. "The epidemiology of diabetes in psychotic disorders". Lancet Psychiatry 2(2015):431-451.
