Antipsychotic drugs are essential for managing psychotic disorders but they increase the risk of diabetes and metabolic syndrome, leading to higher cardiovascular morbidity and mortality. This risk varies between agents, with clozapine and olanzapine showing the highest liability. Mechanisms involve both central hypothalamic effects and peripheral actions on the pancreas, liver, muscle, and adipose tissue, leading to insulin resistance and hormonal dysregulation, sometimes independent of weight gain. Despite longstanding guidelines, metabolic monitoring remains poorly implemented. Systematic screening and early preventive and therapeutic strategies are essential to reduce these complications.