Dr Chaparala asks if we would have been better mentioning how duration of untreated psychosis affects long-term outcomes. Is not a 20-year mortality gap for men, and 15 years for women, a significant long-term outcome and an impact of untreated cardiometabolic risk deserving of some earlier intervention?

Notwithstanding incontrovertible evidence that antipsychotics cause problematic weight gain, we do not suggest antipsychotics are the sole explanation of increased cardiovascular disease, but do highlight how antecedent risks can become established in the critical early treatment phase. This is further supported by another recent systematic review observing cardiometabolic changes only after antipsychotic initiation. ^{Reference Mitchell, Vancampfort, De Herdt, Yu and De Hert1} The subsequent trajectory of weight gain, increasing metabolic disturbance and sustained heavy smoking provides a compelling link between schizophrenia and cardiovascular disease, ^{Reference Newcomer and Hennekens2} the single most important cause of premature death in this population.

Furthermore, the National Institute for Health and Clinical Excellence (NICE) are clear in their recommendations that these adverse cardiovascular risks should be identified at the earliest opportunity and managed using the appropriate NICE guidance for prevention of these conditions (the 2009 updated guidance for schizophrenia, CG82; recommendation 10.4.1.3). And yet when the recent Royal College of Psychiatrists’ National Audit of Schizophrenia (NAS) examined the implementation of NICE recommendations in community settings (NAS report 2012; www.rcpsych.ac.uk/quality/NAS), it found that only 29% of people with schizophrenia across England and Wales had received an adequate assessment of cardiometabolic risk within the previous 12 months; 44% had not even been weighed.

Does this apparent lack of concern about adverse cardiometabolic consequences revealed by the NAS matter? After all, Dr Reed is reassured about antipsychotic safety by the FIN11 study of Tilhonen et al. However, authorities De Hert et al ^{Reference De Hert, Correll and Cohen3} have challenged this study's conclusions, listing methodological weaknesses which include

Dr Reed raises the issue of switching antipsychotics and how this may destabilise control of psychosis but may have missed the point of Weiden's editorial that he refers to. While indeed not advocating switching antipsychotics in someone established on treatment, Weiden highlights how two randomised studies demonstrated the positive value of switching antipsychotics to counteract rapid weight gain and metabolic change, concluding: ‘Practice guidelines and public policy should recommend that clinicians consider the value of switching antipsychotics in patients with elevated metabolic risk.’ ^{Reference Weiden4}

Dr Chaparala suggests we are abandoning antipsychotics. No, but we are in good company in questioning the dominance of psychopharmacology. ^{Reference Tyrer5} Moreover, excessive reliance on antipsychotic treatment is suggested by the NAS finding of wide variation in the availability of psychological treatments across England and Wales: even in those patients whose response to antipsychotics had been unsatisfactory, 34% were not offered any form of psychological treatment despite NICE recommendations that these should be considered.

What we urge is responsible prescribing, particularly in the critical early phase of illness and sensitivity by us as doctors to how these young people may feel about the effects of our treatments. Perhaps the final word should go to the closing comment of Dr Tagore's letter: ‘We must never be economical with the truth about the drugs we are all too happy to dish out.’