Migraine and Despair: Factors Associated with Depression and Suicidal Ideation among Canadian Migraineurs in a Population-Based Study

Risks of suicide in migraine, non-migraine headache, back, and neck pain: a systematic review and meta-analysis

Objective

To conduct a systematic review and meta-analysis on suicidal ideation, attempts, and death in patients with head, neck, and back pain.

Method

Search was performed using PubMed, Embase, and Web of Science from the date of the first available article through September 31, 2021. A random effects model was used to estimate the pooled odds ratios (ORs) and 95% confidence intervals (95% CI) for the association between suicidal ideation and/or attempt and head, back/neck pain conditions. Articles describing non-migraine headache disorders and death by suicide were also reviewed but not included in the meta-analysis due to an insufficient number of studies.

Results

A total of 20 studies met criteria for systemic review. A total of 186,123 migraine patients and 135,790 of neck/back pain patients from 11 studies were included in the meta-analysis. The meta-analysis showed that the estimated risk of combined suicidal ideation and attempt in migraine [OR 2.49; 95% CI: 2.15-2.89] is greater than that in back/neck pain pain [OR 2.00; 95% CI: 1.63-2.45] compared to non-pain control groups. Risk of suicide ideation/planning is 2 folds higher [OR: 2.03; 95% CI: 1.92-2.16] and risk of suicide attempt is more than 3 folds higher [OR: 3.47; 95% CI: 2.68-4.49] in migraine as compared to healthy controls.

Conclusion

There is an elevated risk of suicidal ideation and attempt in both migraine and neck/back pain patients in comparison to healthy controls, and this risk is particularly higher among migraine patients. This study underscores the critical need for suicide prevention in migraine patients.

Associations of migraines with suicide ideation or attempts: A meta-analysis

Objective

Whether migraine is associated with a higher risk of suicide ideation and/or attempts remains controversial. Therefore, we aimed to evaluate these potential associations in migraine patients by performing a meta-analysis of previously published data.

Methods

We searched for studies published up to 31 June 2022 that compared the risk of suicide ideation/attempt in migraineurs and non-migraineurs in PubMed, EMBASE, and Web of Science databases. Sixteen studies fulfilled the eligibility criteria. We applied Random-effects models to calculate pooled adjusted odds ratios (AORs) and 95% confidence intervals (CIs) in patients with migraine.

Results

Migraine patients were at a significantly increased risk of suicide ideation (AOR 1.33, 95% CI 1.15-1.54) and suicide attempts (AOR 1.70, 95% CI 1.42-2.03). The increase in risk may be greater in adults (>19 years) than in younger individuals.

Conclusion

The available evidence indicates a significant association of migraines with suicide ideation and attempts. Future work should confirm and extend these findings, as well as explore whether they are affected by ethnicity or geography.

Association between suicidal risks and medication-overuse headache in chronic migraine: a cross-sectional study

Background

Behaviors of substance dependence are common among patients with medication-overuse headache (MOH). Whether MOH, like other substance use disorders, is associated with an increased risk for suicide is unknown.

Methods

In this cross-sectional study, newly diagnosed chronic migraine (CM) patients with or without coexisting MOH were enrolled prospectively. Headache diagnoses were made through face-to-face interviews by headache specialists, and a specifically designed questionnaire was used to collect demographics, headache profiles, Migraine Disability Assessment, Hospital Anxiety and Depression Scale, Pittsburgh Sleep Quality Index, etc. Suicidal ideation and prior suicide attempt were specifically questioned.

Results

In total, 603 CM patients (485F/118M, mean age 42.03 ± 12.18 years) were recruited, including 320 with MOH (257F/63M, mean age 42.8 ± 11.7 years) (53.1%), and 214 (35.5%) and 81 (13.4%) had suicidal ideation and prior suicide attempt, respectively. Among CM patients, the presence of MOH increased the risks of suicidal ideation (odds ratio [OR] = 1.75 [95% CI = 1.20–2.56], p = 0.004) and prior suicide attempt (OR = 1.88 [1.09–3.24], p = 0.024), after controlling for demographics, headache profile, disabilities, symptoms of anxiety and depression, and sleep quality.

Conclusions

In CM patients, MOH is associated with an increased risk for suicidal ideation and prior suicide attempt, which deserves attention for clinicians taking care of headache patients. However, further studies are needed to determine the causal relationship, as well as the underlying pathophysiology.

Migraine and Mood in Children

Migraine is one of the most prevalent headache disorders in children and negatively influences their quality of life. Physical, social, and school functioning are negatively affected. Mood changes are common in migraineurs and may happen before, during, or after a migraine headache. Children with migraine are not exempt from mood swings. The majority of mood changes occur during the prodromal phase, manifesting as a psychobiological response, e.g., difficulty thinking, trouble concentrating, irritability, higher or lower energy, confusion, and depression. A bi-directional relationship between migraine and mood has been proposed, but mechanisms are not clear. Collectively, a maladaptive stress response has been suggested to explain the inability to balance homoeostatic changes when facing various stressors. Recognizing mood changes and monitoring mood patterns in children with migraine, for example, by various apps and so-called mood monitors, is valuable for better management. A multidisciplinary intervention has been recommended to reduce migraine disability, improve coping strategies, and reduce chronification risks in children with migraine. Pharmacological and non-pharmacological strategies are both available and effective. Biofeedback, relaxation, and cognitive-behavioral therapy yield positive outcomes in pediatric migraine. Developing healthy lifestyle habits (diet, exercise, sleep) also seems to improve migraine in this population.

Is There an Association Between Migraine and Major Depressive Disorder? A Narrative Review

Various studies on the association of migraine with depression are published. The comorbidity may upgrade health conditions up to a critical degree. Besides, the duration of symptoms and treatment may be prolonged. Moreover, these conditions can force substantial financial and social hardships on patients and their families. In this literature review, we intend to examine the evidence obtained on the possible associations between migraine and major depressive disorder (MDD). This review is focused on aminergic neurons. One of the variables associated with patients who experience both of these two diseases might have a history of assault. In migraine and MDD patients, genetic evidence, such as single nucleotide polymorphisms (SNP), was found to be one of the associations. Another theory concluded that actual headache diagnosed in patients who received no treatment manifests a history of anxiety, and later, the patients display severe somatic symptoms. In conclusion, there is a robust molecular genetic background, explaining the relationship between migraines and MDD. This correlated data renders a combination of both diagnoses as single separate entities. However, further studies are encouraged to point out the issue of treatment strategies.

Chirality of Central Nervous System (CNS) Acting Drugs: A Formidable Therapeutic Hurdle Against CNS Diseases

BACKGROUND

Over fifty percent of drugs being used clinically are chiral and 90% of them are racemates. Unfortunately, they have both adverse and beneficial effects on body systems.

METHODS

Because of the erratic effects of chiral compounds on body functional systems, literature search was carried out with a view to identify CNS chiral drugs, their clinical advantages and disadvantages, unique physicochemical properties and structural modifications into safer drugs.

RESULTS

Findings have shown that majority of CNS and non-CNS acting drugs have chiral functional groups that may occur as either dextrorotatory (clockwise) or levorotatory (anticlockwise) or racemates which are inert. Sometimes, the enantiomers (optical isomers) could undergo keto-enol tautomerism, appearing in either acidic or basic or inert form. Chiral CNS acting drugs have agonistic and antagonistic effects, clinical advantages, disadvantages, and special clinical applications, possible modifications for better therapeutic effects and possible synthesis of more potent drugs from racemates. Clockwise chirality may be more effective and safer than the drugs with anticlockwise chirality. When chiral drugs are in racemate state they become inert and may be safer than when they are single. Also, diastereoisomers may be more dangerous than stereoisomers.

CONCLUSION

Therefore, chiral compounds should be adequately studied in lab rodents and primates, and their mechanisms of actions should be comprehensively understood before being used in clinical setting. Since many of them are toxic, their use should be based on principle of individualized medicine. Their molecular weights, functional groups, metabolites, polymers and stereoisomers could be valuable tools for their modifications.

Excess abdominal fat is associated with cutaneous allodynia in individuals with migraine: a prospective cohort study

OBJECTIVE

To investigate the specific relationship between cutaneous allodynia (CA) and the percentages of body fat (BF) and abdominal fat in migraineurs. Additionally, we compared serum levels of inflammatory biomarkers in patients with and without CA.

BACKGROUND

Excess abdominal fat might facilitate progressive changes in nociceptive thresholds causing central sensitization, clinically reflected as CA, which could drive migraine progression.

METHODS

This prospective cohort study included 80 patients with migraine (mean age 39 years, 81.2% female) and 39 non-migraine controls. We analysed each participant's height, body weight, and body mass index (BMI). The amount and distribution of BF was also assessed by air displacement plethysmography (ADP) and ViScan, respectively. We analysed serum levels of markers of inflammation, during interictal periods.

RESULTS

We studied 52 patients with episodic migraine (EM) and 28 with chronic migraine (CM). Of the 80 patients, 53 (53.8%) had CA. Migraineurs with CA had a higher proportion of abdominal fat values than patients without CA (p = 0.04). The independent risk factors for CA were the use of migraine prophylaxis (OR 3.26, 95% CI [1.14 to 9.32]; p = 0.03), proportion of abdominal fat (OR 1.13, 95% CI [1.01 to 1.27]; p = 0.04), and presence of sleep disorders (OR 1.13, 95% CI [00.01 to 1.27]; p = 0.04). The concordance correlation coefficient between the ADP and BMI measurements was 0.51 (0.3681 to 0.6247). CA was not correlated with the mean plasma levels of inflammatory biomarkers.

CONCLUSIONS

There is a relation between excess abdominal fat and CA. Abdominal obesity might contribute to the development of central sensitization in migraineurs, leading to migraine chronification.

Suicide Attempts among Those with Migraine: Findings from a Nationally Representative Canadian Study

The objectives of this study were to identify the gender-specific prevalence of suicide attempts among those with migraine and to examine what factors are associated with suicide attempts among migraineurs. This study was a nationally representative analysis of the 2012 Canadian Community Health Survey - Mental Health (CCHS-MH) with 21,744 respondents, of whom 2,223 had migraine. Bivariate and logistic regression analyses were conducted. Those with migraine had a much higher prevalence of ever attempting suicide than those without migraine (men: 7.5% vs 1.9%; women; 9.3% vs 2.7%, p < .001). Among migraineurs, the odds of suicide attempts were higher among poorer respondents, those in chronic pain and those with a history of childhood adversities, substance dependence and/or mental illness. Targeted outreach is needed to reduce suicidality in this vulnerable population.

Studies on the Mechanism of Glutamate Metabolism in NTG-Induced Migraine Rats Treated with DCXF

Objective

To explore the mechanism of the antimigraine effect by active components extracted from the Dachuanxiong prescription (DCXF), nitroglycerin- (NTG-) induced migraine rats were used to detect the change of glutamate metabolism and the overall metabolic profile at different time points in the serum and Trigeminocervical complex(TCC) samples.

Method

The biological samples that were obtained at 30 minutes, 60 minutes, and 90 minutes after model establishment or drug administration were tested by GC-TOF-MS. Then, real-time PCR and western blot were applied to detect changes in the expression of some substances involved in glutamate metabolism.

Result

DCXF could improve the metabolic profile of serum and TCC in migraine rats and showed the time trend of treatment, mainly involved by amino acid metabolism (glutamate, aspartic acid, and alanine metabolism). In addition, DCXF could increase the expressions of GS at 60 min and 90 min and EAAT1 at 90 min. The results of GS protein were similar to that of mRNA.

Conclusion

The antimigraine effect of DCXF could be achieved by improving the metabolic profile and increasing the expressions of GS and EAAT1 to promote the glutamate cycle of TCC and serum samples in NTG-induced migraine rats to a certain extent.

Global assessment of migraine severity measure: preliminary evidence of construct validity

Background

In persons with migraine, severity of migraine is an important determinant of several health outcomes (e.g., patient quality of life and health care resource utilization). This study investigated how migraine patients rate the severity of their disease and how these ratings correlate with their socio-demographic, clinical, and psycho-social characteristics.

Methods

This is a cohort of 263 adult migraine patients consecutively enrolled in the Neurological Disease and Depression Study (NEEDs). We obtained a broad range of clinical and patient-reported measures (e.g., patients’ ratings of migraine severity using the Global Assessment of Migraine Severity (GAMS), and migraine-related disability, as measured by the Migraine Disability Scale (MIDAS)). Depression was measured using the 9-item Patient Health Questionnaire (PHQ-9) and the 14-item Hospital Anxiety and Depression Scale (HADS). Median regression analysis was used to examine the predictors of patient ratings of migraine severity.

Results

The mean age for the patients was 42.5 years (SD = 13.2). While 209 (79.4%) patients were females, 177 (67.4%) participants reported “moderately severe” to “extremely severe” migraine on the GAMS, and 100 (31.6%) patients had chronic migraine. Patients’ report of severity on the GAMS was strongly correlated with patients’ ratings of MIDAS global severity question, overall MIDAS score, migraine type, PHQ-9 score, and frequency of migraine attacks. Mediation analyses revealed that MIDAS mediated the effect of depression on patient ratings of migraine severity, accounting for about 32% of the total effect of depression. Overall, migraine subtype, frequency of migraine, employment status, depression, and migraine-related disability were statistically significant predictors of patient-ratings of migraine severity.

Conclusions

This study highlights the impact of clinical and psychosocial determinants of patient-ratings of migraine severity. GAMS is a brief and valid tool that can be used to assess migraine severity in busy clinical settings.

Untangling the Association Between Migraine, Pain, and Anxiety: Examining Migraine and Generalized Anxiety Disorders in a Canadian Population Based Study

OBJECTIVE

The aims of this study were to investigate: (1) the prevalence and unadjusted and adjusted odds of 12-month generalized anxiety disorder (GAD) among adults with migraine in comparison to those without migraine; (2) If debilitating pain and/or limitations in instrumental activities of daily living (IADLs) are mediators of the migraine-GAD association; and (3) Factors associated with past year GAD among adults with migraine.

METHODS

Secondary data analysis of the nationally representative 2012 Canadian Community Health Survey-Mental Health (CCHS-MS), a population-based survey of community dwellers with a response rate of 68.9%. The first subsample included those with (n = 2232) and without migraine (n = 19,270), and the second subsample was restricted to those with migraine (n = 2232). GAD was based on the WHO-CIDI scale.

RESULTS

Fully, 6% of those with migraines had past year GAD in comparison of 2.1% of those without migraine (P < .001). The socio-demographically adjusted odds of past year GAD were two and a half times higher among those with migraine than those without (OR= 2.46; 95% CI = 2.00, 3.02). A path analysis indicated that debilitating pain and limitations in IADLs were mediators in the relationship between migraine and GAD. In the sample restricted to migraineurs, the factors associated with higher odds of 12-month GAD included having a university degree, having low income, being without a confidant, and being male.

CONCLUSIONS

Generalized anxiety disorder is robustly associated with migraine and targeted outreach and interventions are warranted.

Familial Aggregation of Migraine and Depression: Insights From a Large Australian Twin Sample

OBJECTIVES

This research examined the familial aggregation of migraine, depression, and their co-occurrence.

METHODS

Diagnoses of migraine and depression were determined in a sample of 5,319 Australian twins. Migraine was diagnosed by either self-report, the ID migraine™ Screener, or International Headache Society (IHS) criteria. Depression was defined by fulfilling either major depressive disorder (MDD) or minor depressive disorder (MiDD) based on the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria. The relative risks (RR) for migraine and depression were estimated in co-twins of twin probands reporting migraine or depression to evaluate their familial aggregation and co-occurrence.

RESULTS

An increased RR of both migraine and depression in co-twins of probands with the same trait was observed, with significantly higher estimates within monozygotic (MZ) twin pairs compared to dizygotic (DZ) twin pairs. For cross-trait analysis, the RR for migraine in co-twins of probands reporting depression was 1.36 (95% CI: 1.24-1.48) in MZ pairs and 1.04 (95% CI: 0.95-1.14) in DZ pairs; and the RR for depression in co-twins of probands reporting migraine was 1.26 (95% CI: 1.14-1.38) in MZ pairs and 1.02 (95% CI: 0.94-1.11) in DZ pairs. The RR for strict IHS migraine in co-twins of probands reporting MDD was 2.23 (95% CI: 1.81-2.75) in MZ pairs and 1.55 (95% CI: 1.34-1.79) in DZ pairs; and the RR for MDD in co-twins of probands reporting IHS migraine was 1.35 (95% CI: 1.13-1.62) in MZ pairs and 1.06 (95% CI: 0.93-1.22) in DZ pairs.

CONCLUSIONS

We observed significant evidence for a genetic contribution to familial aggregation of migraine and depression. Our findings suggest a bi-directional association between migraine and depression, with an increased risk for depression in relatives of probands reporting migraine, and vice versa. However, the observed risk for migraine in relatives of probands reporting depression was considerably higher than the reverse. These results add further support to previous studies suggesting that patients with comorbid migraine and depression are genetically more similar to patients with only depression than patients with only migraine.

Association of Migraine Headaches With Suicidal Ideation Among Pregnant Women in Lima, Peru

BACKGROUND

Suicide is a leading cause of maternal death globally, and suicide prevalence rates have been shown to be increased in those with migraine. No previous study has examined the association between migraine and suicidal ideation during pregnancy.

OBJECTIVE

To examine the association between migraine and suicidal ideation among a cohort of pregnant women.

METHODS

A cross-sectional study was conducted among 3372 pregnant women attending prenatal care clinics in Lima, Peru. Suicidal ideation and depression were assessed using the Patient Health Questionnaire-9 (PHQ-9) scale during early pregnancy. Migraine classification (including migraine and probable migraine) was based on International Classification of Headache Disorders-III beta criteria. Multivariable logistic regression analyses were performed to estimate odds ratios (OR) and 95% confidence intervals (95% CI).

RESULTS

Suicidal ideation was more common among those with migraine (25.6%) as compared to those with probable migraine (22.1%, P < .001) or non-migraineurs (12.3%, P < .001). After adjusting for confounders, including depression, those with migraine or probable migraine had a 78% increased odds of suicidal ideation (OR = 1.78; 95% CI: 1.46-2.17), as compared with non-migraineurs. Women with both migraine and depression had a 4.14-fold increased odds of suicidal ideation (OR = 4.14; 95% CI: 3.17-5.42) compared to those with neither condition.

CONCLUSION

Migraine is associated with increased odds of suicidal ideation in pregnant women even when controlling for depression. These findings support the consideration of screening women with comorbid migraine and depression for suicidal behavior during pregnancy.

Taking the headache out of migraine

Migraine is a disease that contributes to major disability. Perhaps because migraine attacks are not immediately life-threatening per se and individuals return to a "normal" state between attacks, it is not taken seriously. However, migraine is associated with a number of comorbidities, including psychiatric disease, stroke, and other chronic pain disorders. Current acute treatments for episodic migraine are relatively effective, but preventive treatments for episodic and chronic migraine are far less so. Recent functional imaging studies have shown that the disease affects brain function and structure (either as a result of its genetic predisposition or as a result of repeated attacks). The current evidence in the pain field is that changes observed in brain function and structure may be reversible, adding credence to the notion that treating the disease aggressively and early may be beneficial to patients. Here we suggest a change in our approach to a disease that is currently not treated with the urgency that it deserves given its global prevalence, disease burden, and effects on brain function.

Osmophobia and allodynia are critical factors for suicidality in patients with migraine

Background

Sensory hypersensitivities are common phenomena in migraine. We examined the role of sensory hypersensitivities on suicidality in patients with migraine.

Methods

Patients with migraine (with or without aura) were consecutively recruited from our headache clinic. We asked them if they experienced photophobia, phonophobia, osmophobia, and allodynia during migraine attack. The Mini International Neuropsychiatric Interview was used to diagnose current major depressive disorder (MDD), current generalized anxiety disorder (GAD) and suicidality.

Results

Among 220 subjects, 25.5 % had current MDD, 17.3 % had current GAD, and 31.8 % had suicidality. Patients with suicidality were more like to have a low household income, chronic migraine (CM), medication overuse headache, high headache intensity, osmophobia, allodynia, high disability, MDD, and GAD than those without suicidality. The strongest risk factor for suicidality by multivariate analyses was osmophobia (adjusted Odds Ratio [AOR] 3.12, 95 % confidence interval [CI] 1.57-6.21, p = 0.001), followed by current MDD (AOR 2.99, 95 % CI 1.33-6.76, p = 0.008), CM (AOR 2.48, 95 % CI 1.21-5.09, p = 0.013), current GAD (AOR 3.11, 95 % CI 1.22-7.91, p = 0.017), and allodynia (AOR 2.72, 95 % CI 1.19-6.21, p = 0.018).

Conclusions

Osmophobia and allodynia are critical factors for suicidality in patients with migraine, after controlling for depression, anxiety, and CM.

Migraine: multiple processes, complex pathophysiology

Migraine is a common, multifactorial, disabling, recurrent, hereditary neurovascular headache disorder. It usually strikes sufferers a few times per year in childhood and then progresses to a few times per week in adulthood, particularly in females. Attacks often begin with warning signs (prodromes) and aura (transient focal neurological symptoms) whose origin is thought to involve the hypothalamus, brainstem, and cortex. Once the headache develops, it typically throbs, intensifies with an increase in intracranial pressure, and presents itself in association with nausea, vomiting, and abnormal sensitivity to light, noise, and smell. It can also be accompanied by abnormal skin sensitivity (allodynia) and muscle tenderness. Collectively, the symptoms that accompany migraine from the prodromal stage through the headache phase suggest that multiple neuronal systems function abnormally. As a consequence of the disease itself or its genetic underpinnings, the migraine brain is altered structurally and functionally. These molecular, anatomical, and functional abnormalities provide a neuronal substrate for an extreme sensitivity to fluctuations in homeostasis, a decreased ability to adapt, and the recurrence of headache. Advances in understanding the genetic predisposition to migraine, and the discovery of multiple susceptible gene variants (many of which encode proteins that participate in the regulation of glutamate neurotransmission and proper formation of synaptic plasticity) define the most compelling hypothesis for the generalized neuronal hyperexcitability and the anatomical alterations seen in the migraine brain. Regarding the headache pain itself, attempts to understand its unique qualities point to activation of the trigeminovascular pathway as a prerequisite for explaining why the pain is restricted to the head, often affecting the periorbital area and the eye, and intensifies when intracranial pressure increases.

Depression, anxiety and stress among pregnant migraineurs in a pacific-northwest cohort

BACKGROUND

The co-occurrence of migraine and unipolar psychiatric disorders has been well documented in non-pregnant populations, however little is known in pregnant populations.

METHODS

A cohort of 1321 women was interviewed during the first trimester of pregnancy. At the time of interview lifetime migraine status was ascertained using International Classification of Headache Disorders diagnostic criteria (ICHD-II). Information regarding unipolar depression, anxiety and stress during pregnancy was collected using the Patient Health Questionnaire Depression Module-9 (PHQ-9), and the Depression Anxiety Stress Scales 21-item Short Form (DASS-21). Multivariable logistic regression procedures were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the association of migraine and mood disorders during pregnancy.

RESULTS

Approximately 28.2% (N=372) were classified as having a lifetime history of migraine; among migraineurs 122 were classified as migraineurs with aura and 250 as migraineurs without aura. Compared with non-migraineurs, migraineurs were associated with 1.60-fold increased odds of depression as measured by a PHQ-9 score ≥10 (AOR=1.60; 95% CI: 1.12-2.31). Overall, migraine with aura was more strongly associated with depression than was migraine without aura. Migraineurs, as compared with non-migraineurs, also had higher odds of mood disorders as measured by the DASS-21.

CONCLUSIONS

The comorbidity of mood and migraine disorders in pregnant populations supports the need for integrated mental and physical clinical evaluation, increased vigilance, and treatment of patients with such disorders.

Remission from Depression among Adults with Arthritis: A 12-Year Followup of a Population-Based Study

Individuals with arthritis are vulnerable to depression. In this study, we calculated time to remission from depression in a representative community-based sample of depressed Canadians with arthritis who were followed for 12 years. We conducted secondary analysis of a longitudinal panel study, the National Population Health Survey, which was begun in 1994/95 and has included biennial assessment of depression since that time. Our analysis focused on a total of 216 respondents with arthritis who were depressed at baseline. The mean time to remission from depression was calculated using the Kaplan-Meier procedure and compared across categories of each of the potential predictors. The percentage of those no longer screening positive for depression was calculated at two years after baseline. At two years after baseline, 71% of the sample had achieved remission from depression. Time to remission was significantly longer for those depressed adults who were under the age of 55, those who reported more chronic pain at baseline, those with comorbid migraine, and those who experienced childhood physical abuse or parental addictions. These findings highlight the importance of screening for these factors to improve the targeting of interventions to depressed patients with arthritis.