An eleven-year-old metabolic checklist for antipsychotics still misses most patients

A one-page chart has told UK psychiatrists and GPs what to check before starting a patient on an antipsychotic, and what to check again six weeks later, since 2012. The chart was updated in 2023 and NICE endorses it. A 2025 audit of 38 inpatients found the six-week calendar completed for six per cent of them.

Two clinicians, one checklist

The Lester UK Adaptation is built for a handoff. The Royal College of Psychiatrists and the Royal College of General Practitioners publish it jointly, and it assumes a patient moves between a psychiatrist who prescribes and a GP who holds the rest of the chart. Before or at the start of an antipsychotic, or when one is switched, the resource lists a baseline: weight, waist circumference, BMI, blood pressure, HbA1c or fasting glucose, a lipid panel, family history of diabetes, obesity or cardiovascular disease, ethnicity and smoking status. NICE lists it as an endorsed resource for CG178, its psychosis and schizophrenia guideline; the adolescent supplement was added in 2025.

A number for every warning sign

Referral out of psychiatric care is not left to judgment. Total cholesterol above 9 mmol/l, non-HDL cholesterol above 7.5 mmol/l, or triglycerides above 20 mmol/l each send the patient to a specialist on their own. The same numeric logic runs through the weight schedule: weekly weighing for six weeks after a new antipsychotic starts or an existing one changes, because a gain of three to four kilograms in that first month is read as an early signal of the metabolic trajectory the patient is on, not an isolated finding to note and move past.

What actually gets measured

The 2025 audit of 38 patients on four inpatient wards in the East Midlands checked how much of the chart survives contact with a ward. Blood pressure was recorded for 89.5% of patients, HbA1c or glucose for 65.8%, a lipid panel for 57.9%. Weight at baseline dropped to 36.8%. The six-week weekly weight record, the part of the tool built to catch a fast riser before the fast rise becomes a diagnosis, was complete for 5.9% of patients; 41.2% had no weight follow-up documented at all within the window.

The point where two charts diverge

Blood pressure is a single cuff reading taken on admission; a six-week weight series asks someone to find the same patient, on the same ward or the same GP list, every week for a month, and write the number down. The audit's own ranking makes the case on its own: the measurement that took one visit had the highest compliance, the one that needed six had the lowest. For a psychiatrist writing a discharge letter, or a GP receiving one, the six-week box is the one worth naming explicitly rather than folding into a general instruction to monitor.