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In this study, thirty overweight or obese (Body Mass Index (BMI)\u2009&gt;\u200925) participants under 40 years old with schizophrenia spectrum disorders and early comorbid prediabetes or type 2 diabetes receiving antipsychotic medications were randomized, in a double-blind fashion, to metformin 1500\u2009mg\/day or placebo (2:1 ratio; <jats:italic>n<\/jats:italic>\u2009=\u200921 metformin and <jats:italic>n<\/jats:italic>\u2009=\u20099 placebo) for 4 months. The primary outcome measures were improvements in glucose homeostasis (HbA1c, fasting glucose) and insulin resistance (Matsuda index\u2014derived from oral glucose tolerance tests and homeostatic model of insulin resistance (HOMA-IR)). Secondary outcome measures included changes in weight, MRI measures of fat mass and distribution, symptom severity, cognition, and hippocampal volume. Twenty-two patients (<jats:italic>n<\/jats:italic>\u2009=\u200914 metformin; <jats:italic>n<\/jats:italic>\u2009=\u20098 placebo) completed the trial. The metformin group had a significant decrease over time in the HOMA-IR (<jats:italic>p<\/jats:italic>\u2009=\u20090.043) and fasting blood glucose (<jats:italic>p<\/jats:italic>\u2009=\u20090.007) vs. placebo. There were no differences between treatment groups in the Matsuda index, HbA1c, which could suggest liver-specific effects of metformin. There were no between group differences in other secondary outcome measures, while weight loss in the metformin arm correlated significantly with decreases in subcutaneous, but not visceral or hepatic adipose tissue. Our results show that metformin improved dysglycemia and insulin sensitivity, independent of weight loss, in a young population with prediabetes\/diabetes and psychosis spectrum illness, that is at extremely high risk of early cardiovascular mortality. 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