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Pragmatic language impairments-difficulties using language effectively in social contexts-are common in adults suffering from severe mental illnesses (SMIs) such as schizophrenia spectrum disorders (SSD), major depressive disorder (MDD), and bipolar disorder (BD). These impairments hinder social functioning and recovery but have been explored most widely using comprehension tasks, with pragmatic production being poorly described. We undertook a systematic review and meta-analysis of studies assessing expressive pragmatic language in adults with SMIs versus healthy controls. 18 items were tested, including Coherence, Cohesion, Gricean maxims, figurative language, Prosody, and Turn-Taking. The searches were PRISMA-compliant and were conducted in PubMed and Scopus. 51 studies were included; 28 were meta-analyzed. Results showed significant impairments in Cooperativity, Anaphora and Cohesion, moderate impairments in Coherence, and low impairments in Metaphor. No significant moderator was detected. Our results emphasize the need for standardized pragmatic testing and intervention for language production in clinical settings.