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I was very interested in the paper by Gumber et al, 1 which examined the monitoring of metabolic side-effects of antipsychotics in patients with schizophrenia. I commend them for their attempts to follow guidance for this monitoring and I agree that metabolic side-effects are important considerations for this group of patients. However, my critical review of the evidence of risk to patients with mental illness does not support the use of such widespread monitoring.

I will use the example of lipid monitoring to illustrate this. A large general practice study in the UK 2 found that the relative risk of death from cardiovascular disease in people with mental illness when compared with controls was highest in younger people and reduced with age to a point that was not statistically significant in people over the age of 75. The authors of that study claim that the three-fold increase in deaths for people under the age of 50 is the most worrying. This may be so, but the finding is worthy of closer scrutiny, especially when the implications for screening are being considered. In fact, the absolute risk of death from coronary heart disease in people with mental illness aged 18-49 was 0.1% over a median follow-up period of 4.7 years.

European guidelines for prevention of heart disease 3 recommend monitoring of lipids only when the 10-year risk reaches 5% or more. It would seem difficult therefore to justify routine monitoring of mentally ill people aged 18-49.

Also of concern is the lack of evaluation of harm to patients caused by what is essentially a screening programme of high-risk individuals. Such programmes are known to be associated with harm in a variety of forms. These include overdiagnosis, overtreatment and anxiety concerning the illness being investigated. 4

Last, for a patient to give informed consent to participate in this kind of programme, they should be informed of the uncertainties inherent in it and the likelihood or otherwise of benefit to them of such a screening.

It is time to take stock and critically review which, if any, of these investigations are necessary for our patients.

1 Gumber, R, Abbas, M, Minajagi, M. Monitoring the metabolic side-effects of atypical antipsychotics. Psychiatrist 2010; 34: 390–5.
2 Osborn, DP, Levy, G, Nazareth, I, Petersen, I, Islam, A, King, MB. Relative risk of cardiovascular and cancer mortality in people with severe mental illness from the United Kingdom's General Practice Research Database. Arch Gen Psychiatry 2007; 64: 242–9.
3 Fourth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice. European guidelines on cardiovascular disease prevention in clinical practice: executive summary Eur J Cardiovasc Prevent Rehabil 2007; 14 (suppl 2): E140.
4 Jørgensen, K, Gøtzsche, P. Content of invitations for publicly funded screening: mammography. BMJ 2006; 332: 538–41.