Combination therapy with an atypical antipsychotic and metformin may be an attractively simple solution but more data from larger, long-term, preferably primary care-based trials are required to test this approach. In the meantime, we should be closely monitoring weight gain and cardiovascular risk in patients newly started on atypical antipsychotics, bearing in mind that the Framingham risk score underestimates risk in obese patients with the metabolic syndrome.