Metabolic syndrome, obesity, diabetes and other cardiovascular risk factors are highly prevalent in people with SMI. Patients are at risk for premature mortality and the mortality gap with the general population has increased over recent decades. In part these cardio-metabolic risk factors are attributable to unhealthy lifestyle, including poor diet, high rates of smoking, alcohol/substance use/abuse and sedentary behaviour. But over recent years it has become apparent that antipsychotic agents and other psychotropic agents can have a negative impact on some of the modifiable risk factors. Also other somatic co-morbid disorders are also linked to antipsychotic treatment such as the consequences of hyperprolactinaemia, QTc-prolongation and constipation. Other somatic disorders such as poor dental care, HIV and other infectious diseases and some forms of cancer are also more prevalent in patients with schizophrenia. People with SMI also have limited access to effective screening and somatic care. The psychiatrist needs to be aware of the potential somatic side-effects of antipsychotic medication and to include them in the risk/benefit assessment when choosing a specific antipsychotic. He should also be responsible for the implementation of the necessary screening assessments and referral for treatment of any physical illness. Multidisciplinary assessment of psychiatric and medical conditions is needed. The somatic treatments offered to people with severe and enduring mental illness should be at par with general health care in the non-psychiatrically ill population.