I read the editorial by Shiers et al ^{Reference Shiers, Bradshaw and Campion1} with some interest largely due to my previous attempts at highlighting this issue both in mental health trusts and to the readership by previous responses and articles.

However, I have been left mildly disappointed again with the tenor of the article, which did not mention the increased risks of mortality without treatment: something an editorial in the BJPsych should be mentioning! We have several past and recent longitudinal studies ^{Reference Tiihonen, Mittendorfer-Rutz, Torniainen, Alexanderson and Tanskanen2} which clearly highlight the risks of increased mortality without antipsychotic treatment. I have followed this trend of certain health professionals not advising patients to go on to antipsychotic medication because of risks to physical health. The trend took a further (dangerous) turn when a study was granted ethical approval which allowed patients with psychotic symptoms not to be treated with antipsychotic medication, ^{Reference Morrison, Turkington, Pyle, Spencer, Brabban and Dunn3} and some regarding it as a proof of concept that cognitive therapy is an alternative to antipsychotics.

An article in the BPsych ^{Reference Jauhar, McKenna, Radua, Fung, Salvador and Laws4} clearly discredited cognitive–behavioural therapy as a viable alternative, but was not given the same media coverage as the pilot study by Morrison et al. ^{Reference Morrison, Turkington, Pyle, Spencer, Brabban and Dunn3} My day-to-day work involves being based in an early intervention team and despite being aware of what needs to be done to monitor physical health, poor investment and increased demand (with the upper age limit now correctly abandoned, see www.nice.org.uk/guidance/cg178/chapter/1-recommendations#first-episode-psychosis-2), we struggle to monitor all our patients to the standard we would like to achieve.

Despite the above factors, there are other issues to consider, including the stigma of the diagnosis and taking medication, lack of family support and working memory deficits ^{Reference Lui, Liu, Chui, Li, Geng and Wang5} to name a few, but readily ignored. I wish the editorial could take a more unbiased role rather than continue to bash on about one factor, i.e. antipsychotic medication and its side-effects. Untreated patients also have higher morbidity risks, which I feel the editorial did not highlight.

Looking at it from a systems theory point of view would have led to a more balanced reading. However, I laud the attempt of this editorial and the attempt to reduce the inequalities and mortality gap. ^{Reference Crump, Winkleby, Sundquist and Sundquist6}