I commend De Hert et al ^{Reference De Hert, Vancampfort, Correll, Mercken, Peuskens and Sweers1} for their attempt to clarify appropriate monitoring for cardiometabolic risk in schizophrenia. I agree that cardiometabolic risk is one important consideration for these patients.

I note that their findings included generally low scores for the rigour of existing guidelines and a lack of evidence of long-term patient outcomes. It is perhaps a little surprising then that they nevertheless make recommendations on what appears to be less than robust evidence.

I have previously expressed concerns that cardiometabolic screening programmes of this type are unevaluated and that the benefits are unknown, as are the risks, which seem to have received little attention. ^{Reference Reed2}

The authors quite rightly highlight that guidelines can be biased because of lack of scientific evidence, but the evidence they present to support their protocol appears to fall well short of the levels of evidence recommended for interventions. ³ I can find no evidence that patients will benefit from such a protocol, and none that they will not be harmed.

I also note that their suggested protocol differs from National Institute for Health and Clinical Excellence (NICE) quality and outcomes framework standards for mental illness (www.nice.org.uk/aboutnice/qof/indicators.jsp) and NICE guidelines for lipid modification, both of which recommend primary preventive screening for patients aged over 40. ⁴

I wish to support the notion that interventions should be evaluated before implementation. ³