Notwithstanding the premorbid genetic and psychosocial predispositions Bailey et al refer to, ^{Reference Bailey, Gerada, Lester and Shiers1} the authors also correctly highlight the incontrovertible evidence that the obesity and metabolic syndrome epidemic we are facing is largely drug induced, as highlighted by the EUFEST study. ² Given this, we must accept that we are essentially complicit in greatly increasing our own patients’ morbidity and mortality, and that this ‘epidemic within an epidemic’ is iatrogenic. I cannot help but wonder whether we, as clinicians, tend to ignore a side-effect which we consider to be ‘benign’, in relation to the perceived lack of an immediate need to address it urgently, as opposed to, for example, an acute extrapyramidal side-effect, massively raised prolactin or marked electrocardiogram changes. I wonder whether our complacency in addressing this adverse effect profile may be borne out of a sense of our own helplessness. That is to say, because there is no straightforward solution to this multifaceted problem, we choose to ignore or at least sidestep the issue. It is precisely because of the creeping, insidious nature of these obesity-related problems that we are allowing them to develop into an ‘epidemic’ of such proportions.

We must ask ourselves whether it is morally acceptable to treat chronic and enduring mental illness at the expense of inflicting chronic and enduring physical illnesses. As the authors allude, if we actually bothered to ask our patients, particularly the younger ones, what it is they would be most distressed by - continued mental illness or aggressive weight gain - would it really be so surprising that a sizeable proportion would prefer to remain distressed by (or learn to cope with) their psychiatric symptoms than become morbidly obese? Should this really come as a shock to us, given the strongly body-conscious world in which we live? I suspect that our priorities as psychiatrists may not be entirely aligned with those of many of our patients. Is there a doctor-patient risk-benefit analysis mismatch at play here?

But are we really improving our patients’ quality of life and promoting social inclusion by treating one stigmatising condition for another, which arguably carries even greater prejudice? After all, most of the population view morbidly obese people not only as a repulsive eyesore, but tend to apportion blame. Many view obesity as a self-inflicted condition, borne purely out of laziness and gluttony, and tend to make extremely pejorative judgements.

Notwithstanding this, although antipsychotics are the only truly effective weapons in our armament against chronic psychotic disorders, it is incumbent on us to make prescribing decisions which take from the outset the potential ramifications of such physically and socially disabling adverse effects into account.

At the end of the day, if I was a patient, I would not be happy to learn that I had developed a serious, chronic physical disorder with many potential multisystem complications (such as diabetes) as a result of taking a drug which I probably was not keen to take in the first place anyway, and was never fully appraised of the risks. We must never be economical with the truth about the drugs we are all too happy to dish out.