Metabolic health in severe mental illness: bridging the mortality gap - a narrative review

People with severe mental illness (SMI) continue to experience a marked mortality gap, driven largely by preventable cardiometabolic conditions. This review examines recent advances in metabolic health that move the field beyond monitoring towards earlier, more proactive, and better integrated interventions.

Recent pharmacological evidence supports metformin's role in mitigating antipsychotic-induced weight gain, and also supports glucagon-like peptide-1 receptor agonists as effective treatments for established obesity and dysglycaemia in SMI. Evidence for behavioural interventions suggests that meaningful improvement, including remission of metabolic syndrome, is achievable when interventions are sufficiently intensive, tailored, and embedded within routine care, rather than delivered as low-intensity education alone. Updated clinical guidance endorses a "screen and intervene" approach and promotes integrated models of mental and physical healthcare, but major implementation gaps remain, particularly in low- and middle-income settings. Finally, emerging genetic and biological evidence indicates that metabolic dysfunction may be partly intrinsic to SMI, underscoring the clinical relevance of metabolic psychiatry.

Metabolic health in SMI should now be considered a core therapeutic target. The central challenge is not only recognising the problem, but also implementing effective metabolic interventions, at scale, across diverse, often siloed, care settings.