PROGRESS in reducing early mortality in severe mental illness

People with severe mental illness have a notably lower life expectancy of up to 20 years compared with their unaffected peers in the general population, Prof Brian O’Donoghue, Professor of Psychiatry, University College Dublin and St Vincent’s University Hospital, Dublin, and Consultant Psychiatrist, Dublin Southeast Mental Health Service, told the College of Psychiatrists of Ireland and Royal College of Psychiatrists in Northern Ireland Winter Conference 2025.

The causes of these early deaths are attributable to cardiovascular, respiratory, and oncological diseases – as in the general population – but their prematurity is often due to the fact that people with serious mental health disorders have a higher, and often earlier, exposure to modifiable risk factors like smoking, dyslipidaemia, sedentary lifestyle, poor diet, and in particular, obesity, delegates heard. Therefore, “it’s really about early intervention,” he said.

Prof O’Donoghue presented on behalf of the PROGRESS research group, which is developing clinical guidelines, information resources, and digital tools to support clinicians and patients with psychotic disorders. Its recently published Guideline on metformin for prevention of antipsychotic-induced weight gain marks a notable development in mental health.

The first episode of psychosis is “one of the most distressing times of a person’s life”, Prof O’Donoghue said, adding that within a year of their first episode, one-quarter of these patients will also have obesity.

“This figure rises to between 60 and 80 per cent among chronic populations. The two biggest risk factors for weight gain are the antipsychotic medications prescribed and age…. Young people and those with a normal or low BMI [body mass index] are much more susceptible to weight gain than older people with higher BMIs.”

Delegates heard that although no antipsychotic medications are free from weight gain side-effects, some carry much higher risk than others. Prof O’Donoghue emphasised the role lifestyle modifications like diet and exercise play, but noted that “they don’t completely prevent weight gain” and “take time to work”. He then went on to discuss the specific guideline recommendations.

Metformin should be co-commenced with a high-risk antipsychotic like olanzapine or clozapine, the conference heard. When commencing medium-risk antipsychotics like quetiapine, paliperidone, or risperidone, Prof O’Donoghue recommended co-commencing metformin if the person has another cardiovascular risk factor or if they are young.

“For the remainder of people on these medium-risk medications, and those on low-risk medications, we recommend monitoring weight very carefully, and if the person gains more than 3 per cent of their body weight within the year, we then recommend they are started on metformin. The rationale for this is that clinically significant weight gain is around 5 per cent and we want to prevent that.”

Prof O’Donoghue went on to note that people who already meet the criteria for clinical obesity should have access to glucagon-like peptide-1 receptor agonists. Acknowledging the availability and cost issues that surround these therapies, he concluded that these patients should have preferential consideration in view of their significant early mortality risks.