Individuals suffering from psychotic disorders have increased comorbidity with chronic organic disorders and reduced life expectancy compared to their healthy peers. Particularly, individuals diagnosed with schizophrenia have a life expectancy 10–20 years shorter than average.¹ The main factor contributing to this increased comorbidity and mortality from natural causes is cardiovascular diseases resulting from higher rates of metabolic syndrome (MetS), obesity, diabetes mellitus, sedentary lifestyle, poor diet, and smoking.² MetS, specifically, is defined by the coexistence of a combination of risk factors such as high blood pressure, high blood glucose levels, excessive fat around the waist, high levels of triglycerides, and low levels of high-density lipoprotein (HDL).

These aggravating factors occur more frequently in individuals with psychosis than in control groups from the very onset of symptoms. For example, the prevalence of MetS was found to be 13.2% higher than in the general population in patients who had never taken antipsychotic drugs and presented with first episode psychosis (FEP).³ Similarly, blood pressure, waist circumference, and fasting glucose have been reported to be slightly higher in antipsychotic‑naïve ultra high risk (UHR) individuals, while lower HDL levels have been demonstrated in FEP adolescents who have never taken medication.⁴

Moreover, initiating treatment with second-generation antipsychotics is associated with rapid and significant weight gain, depending on the specific drug, within the first three months of treatment.⁵ This indicates that between 33% and 61% of individuals with FEP experience clinically significant weight gain, defined as an increase of ≥7% of initial body weight within the first 12 weeks of treatment, and certain parameters of MetS progressively deteriorate over the first year of treatment.^6,7

The above findings have prompted the implementation of various interventions, both pharmaceutical and non-pharmaceutical, in individuals with FEP, aiming at reducing the burden associated with antipsychotic use, which remains the therapeutic standard despite its side-effect profile. These interventions are extended beyond medication-related adverse effects and target other parameters that increase cardiometabolic risk, such as poor diet, lack of physical activity, tobacco and alcohol use, and inadequate physical care.⁸ The effectiveness of these interventions varies, but combining them and implementing them in an organized framework with a holistic approach appears to be the optimal choice. In Greece, this type of comprehensive care is delivered through Early Intervention Services (EIP), where the physical health of patients with FEP is prioritized as a core treatment objective. This is achieved through detailed and systematic recording of medical data, monitoring the key parameters in accordance with international guidelines, and collaborating with primary care services.

International guidelines suggest best practices for recording and treating MetS, and attempts are now underway to estimate the likelihood of MetS emerging from the early stages of psychosis.⁹ One example of such best practice guidelines is the “Lester positive cardiometabolic resource” algorithm, which is the version used in the UK by the iphys initiative, summarizing key indicators and target values for young individuals with psychosis.¹⁰ Tables of the algorithm list the parameters for lifestyle habits (smoking, diet, activity), obesity (weight, BMI, waist circumference), hypertension, glucose levels, and lipid markers. Baseline measurements for each parameter are categorized into three levels: high risk, medium risk, and a target range to be achieved. In this way and with guidance on recommended monitoring frequency (i.e., blood pressure measured at baseline and every three months thereafter), the tool constitutes a practical resource for assessing physical health problems and planning appropriate interventions.

Enhancing the physical health of individuals with FEP requires adopting best practices and providing information and cooperation with primary health care providers within the framework of EIP, as well as with all mental health professionals involved in patient care. Coordinated practice is essential, as physical health outcomes substantially influence both the course of the illness and patients’ functional recovery.

Evangelos Ntouros
2nd Department of Psychiatry, Aristotle University of Thessaloniki
PNOES SKG, Association for Regional Development and Mental Health (EPAPSY)

Stefanos Dimitrakopoulos
PNOES Ath, Association for Regional Development and Mental Health (EPAPSY)

Venetsanos Mavreas
Scientific Board, Association for Regional Development and Mental Health (EPAPSY)

Vasilios-Panteleimon Bozikas
2nd Department of Psychiatry, Aristotle University of Thessaloniki 

References

1. Hjorthøj C, Stürup AE, McGrath JJ, et al. Years of potential life lost and life expectancy in schizophrenia: a systematic review and meta-analysis. Lancet Psychiatry 2017, 4:295–301, https://doi. org/10.1016/S2215-0366(17)30078-0
2. Zierotin A, Murphy J, O’Donoghue B, et al. The short-, medium-, and long-term prevalence of physical health comorbidities in first-episode psychosis: a systematic review and meta-analysis protocol [version 2; peer review: 3 approved]. 2025, https://doi. org/10.12688/hrbopenres.13810.1
3. Garrido-Torres N, Rocha-Gonzalez I, Alameda L, et al. Metabolic syndrome in antipsychotic-naïve patients with first-episode psychosis: A systematic review and meta-analysis. Psychol Med 2021, 51:2307–2320, https://doi.org/10.1017/S0033291721002853
4. Misiak B, Stańczykiewicz B, Łaczmański Ł, et al. Lipid profile disturbances in antipsychotic-naive patients with first-episode non-affective psychosis: A systematic review and meta-analysis. Schizophr Res 2017, 190:18–27, https://doi.org/10.1016/J.SCHRES.2017.03.031
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6. Bioque M, García-Portilla P, García-Rizo C, et al. Evolution of metabolic risk factors over a two-year period in a cohort of first episodes of psychosis. Schizophr Res 2018, 193:188-196, https://doi. org/10.1016/j.schres.2017.06.032
7. Alonso Y, Miralles C, Algora MJ, et al. Risk factors for metabolic syndrome in individuals with recent-onset psychosis at disease onset and after 1-year follow-up. Sci Rep 2022,12:1–11, https://doi. org/10.1038/s41598-022-15479-x
8. Galderisi S, De Hert M, Del Prato S, et al. Identification and management of cardiometabolic risk in subjects with schizophrenia spectrum disorders: A Delphi expert consensus study. Eur Psychiatry 2021, 64:e7, https://doi.org/10.1192/J.EURPSY.2020.115
9. Perry BI, Osimo EF, Upthegrove R, et al. Development and external validation of the Psychosis Metabolic Risk Calculator (PsyMetRiC): a cardiometabolic risk prediction algorithm for young people with psychosis. Lancet Psychiatry 2021, 8:589–598, https://doi. org/10.1016/S2215-0366(21)00114-0
10. Perry BI, Mitchell C, Holt RIG, et al. Lester positive cardiometabolic resource update: improving cardiometabolic outcomes in people with severe mental illness. Br J Gen Pract 2023, 73:488–489, https:// doi.org/10.3399/BJGP23X735273

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