I ask because I have been on both sides. I live with bipolar disorder type 2, which involves episodes of depression and hypomania (or, as I tend to explain it, “not the full-blown kind”). For example, one of my own hypomanic achievements has briefly included becoming one of ASOS’s most committed customers. ASOS has since banned me from free returns, providing a level of monitoring and consequence management that healthcare services may wish to study. This is the side people find easy to laugh at. The other side of bipolar disorder is not. The elevated moods can be chaotic and conspicuous. The lowest lows can reduce life to getting through the next few minutes, while your own mind argues that everybody would be better off without you.
Then, in 2025, I developed chronic vestibular migraine, a neurological condition that leaves me dizzy on most days ending in “y”. Vestibular migraine is a physical illness. Unfortunately, the brain has declined to organise itself according to NHS departmental boundaries.
Severe mental illness can be frightening, disruptive and dangerous at either extreme. That is why psychiatric history and previous reactions to medicines should matter before treatment begins, not only after something has gone wrong. Several medicines used to prevent migraine carry recognised psychiatric risks, including low mood and, for some people, suicidal thoughts. Yet they are generally prescribed by neurologists and GPs, not mental health services.
So, I spent the past year finding out how this is governed. In a personal capacity, I made more than thirty Freedom of Information requests to twenty-six NHS and national organisations. I asked what systems existed to ensure that a patient’s psychiatric history and previous reactions were considered before migraine medicines with recognised mental health risks were prescribed. The resulting report, Heads I Win, Minds You Lose, found no consistent framework for doing this. Organisations often relied on individual clinical judgement, general prescribing information and the expectation that somebody else would notice the risk. There was no clear, system-wide approach to considering psychiatric history, previous adverse reactions, liaison with mental health services, or recording why a medicine was considered safe for that particular patient – a risk often printed on the label and owned by no one in the room.
In other words, my report shows that the brain appears to exist in a Bermuda Triangle. Neurology may assume psychiatry is minding the mind. Psychiatry may assume the physical health prescriber is monitoring the medicine. Primary care may assume somebody at the hospital has a spreadsheet and is checking the patient’s medical history.
Since the report was published, it has prompted follow-up across the system. The Care Quality Commission (CQC) has explained how the issues relate to its standards for medicines safety, shared care and consideration of patients’ physical and psychological histories, and a response is awaited on whether the provider evidence will be recorded as regulatory intelligence. A coordinated response is also awaited from NHS England. The Department for Health and Social Care (DHSC) has acknowledged that it has not made a specific assessment of the national arrangements raised in the report. Separately, The Medicines and Healthcare products Regulatory Agency (MHRA) has confirmed it plans to gather the available evidence on mental health and related risks across licensed migraine preventatives, although no formal timetable has yet been agreed.
Migraine is where I found the gap, but I doubt it ends there. The same question arises when medicines used to treat physical health conditions can affect mood, sleep, thinking or suicidal thoughts, particularly in neurology and pain management. The interface between two systems belongs to neither of them, so too often it belongs to nobody.
Equally well has to mean equally well in both directions.
Author: Fran Gilmore
About the author
Francine Gilmore has a professional background in public policy, regulation and legislation. In a personal capacity, she researches and writes on patient safety, including this governance review of migraine care, mental health and medicines safety. She brings professional expertise and lived experience to the question of how governance can close the gap between the care people are entitled to and the care they actually receive.
