Type 2 diabetes is a serious, debilitating disease disproportionately affecting persons with severe mental illness (SMI). Whereas 4% of the U.S. population has type 2 diabetes, prevalence in individuals with SMI is almost twice as high1 and reaches a staggering 16 to 25% in individuals diagnosed with schizophrenia. Because of the strong association between diabetes and cardiovascular disease, the number-one cause of early mortality in individuals with SMI diabetes is a healthcare issue of epidemic proportions in this population. The increased prevalence is multiply determined by family history, lifestyle, and iatrogenic causes. A major contributor is widespread treatment with second-generation (atypical) antipsychotics, which are associated (to varying degrees) with substantial weight gain, dyslipidemia, and increased risk for type 2 diabetes. However, recent evidence indicates that schizophrenia and bipolar disorder are risk factors independent of antipsychotic use, and lifestyle factors associated with weight gain and diabetes, such as poor diet and physical inactivity, are also common in this group. The costs of this epidemic are high: poor health, early mortality, reduced quality of life, and related decreased opportunity for recovery. Fortunately, early identification and treatment of diabetes may reduce diabetes-related symptoms and prevent or slow progression of metabolic, cardiovascular, and neuropathic disease. Unfortunately, poor access to and utilization of primary care services among individuals with SMI make these positive outcomes often unattainable.