analogous results from research into schizophrenia24)
but all participants who completed the experimental
treatment reported treatment gains. The effects of the
experimental treatment were large and may have been
reduced because some patients in the control group
will have probably tried to recognise prodromal symp-
toms of relapse on their own.10
The experimental treatment does not require a
skilled therapist, but attention to detail is essential to
identify accurately the nature and timing of prodromal
symptoms of manic relapse. Cost effectiveness studies
of the identification of manic prodromes followed by
early treatment are required before the intervention is
systematically introduced into the NHS.
We thank Brian Faragher for statistical advice and our
colleagues in South Manchester, Guild (Preston), Trafford, and
Stockport NHS Trusts who referred patients.
Contributors: NT and RM designed the protocol, initiated
and coordinated the study, successfully applied for funding,
interpreted the data, and wrote the paper. NT and RM are guar-
antors of the study. NT and AP designed the experimental treat-
ment and NT supervised AP in delivering the experimental
treatment. AP, EMcC, and RM analysed the data. AP, KL, and
EMcC recruited patients into the trial and executed the trial.
Funding: This study was funded by a project grant awarded
by the North West Regional Health Authority.
Competing interests: None declared.
1 American Psychiatric Association. Diagnostic and statistical manual of men-
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Coryell W, Keller M, Endicott J, Andreasen N, Clayton P, Hirschfeld R.
Bipolar II illness: course and outcome over a five year period. Psychol Med
Harrow M, Goldberg JF, Grossman LS, Meltzer HY. Outcome in manic
disorders.A naturalistic follow-up study. Arch Gen Psychiatry 1990;47:665-
Tohen M, Waternaux GM, Tsuang MT. Outcome in mania: a 4 year pro-
spective follow-up of 75 patients utilising survival analysis. Arch Gen Psy-
Keller MB, Lavori PW, Coryell W, Endicott J, Mueller TI. Bipolar I: a five
year prospective follow up. J Nerv Ment Dis 1993;181:238-45.
6 Gitlin MJ, Swendsen J, Heller TL, Hammen C. Relapse and impairment
in bipolar disorder. Am J Psychiatry 1995;152:1635-40.
Keck PE, McElroy SL, Strakowski SM, West SA, Sax KW, Hawkins JM,
et al. 12 month outcome of patients with bipolar disorder following
hospitalisation for a manic or mixed episode. Am J Psychiatry 1998;155:
Molnar G,Feeney M,Fava G.The duration and symptoms of bipolar pro-
dromes. Am J Psychiatry 1988;145:1575-8.
Smith J, Tarrier N. Prodromal symptoms in manic depressive psychosis.
Soc Psychiatry Psychiatric Epidemiol 1992;27:245-8.
10 Lam D, Wong G. Prodromes, coping strategies, insight and social
functioning in bipolar affective disorders. Psychol Med 1997;27:1091-100.
11 Altman ES, Rea MM, Mintz J, Miklowik DJ, Goldstein MJ, Hwang S. Pro-
dromal symptoms and signs of bipolar relapse: a report based on
prospectively collected data. Psychiatr Res 1992;41:1-8.
12 Keller MB, Lavori PW, Kane JM, Gelenberg AJ, Rosenbaum JF, Walzer
EA, et al. Subsyndromal symptoms in bipolar disorder: a comparison of
standard and low serum levels of lithium. Arch Gen Psychiatry
13 Spitzer RL,Williams JBW,Gibbon M,First MB. Structured clinical interview
for DSM-III-R,patient edition. Washington, DC: APA, 1990.
14 Pocock ST. Clinical trials:a practical guide. Chichester: Wiley, 1983.
15 Kessing LV. Recurrence in affective disorder. II. Effect of age and gender.
Br J Psychiatry 1998;172:29-34.
16 Maj M, Pirozzi R, Magliano L, Bartoli L. Long-term outcome of lithium
prophylaxis in bipolar disorder: a 5-year prospective study of 402
patients at a lithium clinic. Am J Psychiatry 1998;155:30-6.
17 Miklowitz D, Goldstein M, Nuechterlein K, Snyder M, Mintz J. Family fac-
tors and the course of bipolar affective disorders. Arch Gen Psychiatry
18 Perry A, Tarrier N, Morriss R. Identification of prodromal signs and
symptoms and early intervention in manic depressive psychosis patients:
a case example. Behav Cognit Psychother 1995;23:399-409.
19 Young MA, Grabler P. Rapidity of symptom onset in depression. Psychiatr
20 Hurry J, Sturt E, Bebbington P, Tennant C. Socio-demographic
associations with social disablement in a community sample. Soc Psychia-
21 World Health Organisation. Anatomical therapeutic chemical (ATC) classifi-
cation index including defined daily doses (DDDs) per plan substances. Oslo:
WHO Collaborating Centre for Drug Statistics and Methodology, 1994.
22 Hlastala SA, Frank E, Mallinger AG, Thase ME, Ritenour AM, Kupfer DJ.
Bipolar depression: an underestimated treatment challenge. Depression
23 Gater RA, Dean C, Morris J. The contribution of childbearing to the sex
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24 Tarrier N, Yusupoff L, Kinney C, McCarthy E, Gledhill A, Haddock G, et
al. Randomised controlled trial of intensive cognitive behaviour therapy
for patients with chronic schizophrenia. BMJ 1998;317:303-7.
(Accepted 28 October 1998)
Association between maternal anxiety in pregnancy and
increased uterine artery resistance index: cohort based
Jerónima M A Teixeira, Nicholas M Fisk, Vivette Glover
Objective To investigate whether maternal anxiety in
the third trimester is associated with an increased
uterine artery resistance index.
Design Cohort based study.
Subjects 100 pregnant women, with a mean gestation
of 32 weeks.
Outcome measures Self rating Spielberger
questionnaire for state anxiety and trait anxiety, and
uterine blood flow waveform patterns as assessed by
colour Doppler ultrasound.
Results A significant association was found between
uterine artery resistance index and scores for both
Spielberger state anxiety and trait anxiety (rs= 0.31,
P < 0.002 and 0.28 P < 0.005 respectively). Women
with state anxiety scores > 40 (n = 15) had a higher
mean uterine resistance index than those with scores
<40 (mean difference with mean resistance index
24%, 95% confidence interval 12% to 38%;
P < 0.0001). Similarly, women with trait anxiety scores
> 40 (n = 32) had a higher mean resistance index
than those with scores <40, although to a lesser
extent. The presence of notches in the waveform
pattern produced by uterine artery blood flow was
found in 4/15 (27%) women with high state anxiety
scores compared with 4/85 (5%) with low anxiety
scores (P < 0.02).
Conclusions This study shows an association
between maternal anxiety in pregnancy and increased
uterine artery resistance index. It suggests a
mechanism by which the psychological state of the
mother may affect fetal development, and may explain
epidemiological associations between maternal
anxiety and low birth weight. The influence of
maternal anxiety may be one mechanism by which
Centre for Fetal
Care, Division of
Jerónima M A
Nicholas M Fisk,
professor of obsetrics
reader in perinatal
BMJ VOLUME 31816 JANUARY 1999 www.bmj.com
the intrauterine environment contributes to later
disease in offspring.
The belief that a mother’s psychological state can influ-
ence her unborn baby exists in most societies.1Some
studies have shown that babies of stressed or anxious
mothers have a significantly lower average birth weight
for gestational age and tend to be born early.2–5In one
large case-control study, the magnitude of the effect of
stress on birth weight was similar to that found in the
offspring of mothers who smoked.6As low birth weight
seems to be associated with health problems in later
life—for example, hypertension and ischaemic heart
disease—this is of concern.7Ultrasound studies have
shown that fetal behaviour is affected by maternal
anxiety.8 9Animal studies have also shown that when
the mother is stressed during pregnancy, birth weight
is reduced and the behaviour of the progeny is perma-
nently affected.10 11
There are several mechanisms by which maternal
stress or anxiety might affect the fetus. Increased
concentrations of hormones in the mother may be
transported directly across the placenta.12Blood flow to
the baby may also be impaired through the uterine
arteries.Such an effect has been shown in primates,but
has not yet been studied in humans.13We tested the
associated with abnormal blood flow in the uterine
arteries. This was assessed by using colour Doppler
ultrasound to both measure uterine artery resistance
index and to detect the presence of notches in the
waveform pattern produced by uterine blood flow (fig
1). A notch indicates particularly high resistance to
blood flow. These variables have previously been asso-
ciated with adverse obstetric outcome,particularly fetal
growth restriction and pre-eclampsia.14–16
Subjects and methods
Between April and December 1996, we asked 182
pregnant women at parentcraft classes if they would
agree to participate in our study. Overall, 119 women
with singleton pregnancies between 28 and 32 weeks
of gestation agreed to participate within the next four
weeks. Women who refused to participate did so
mainly because of a lack of a mutually convenient
appointment time; the proportion of these women
(n = 63) with pre-eclampsia (n = 3) and small for
gestational age babies at birth ( < 5th centile; n = 3)
was similar to the final cohort. We obtained informed
written consent from each woman. We excluded
women on the basis of the following criteria: (a) medi-
cal disease, includingknown
antepartum haemorrhage, (b) smoking, (c) previous
adverse obstetric outcome, such as preterm delivery
and small for gestational age baby, (d) assisted concep-
tion, (e) abnormal volume of amniotic fluid or
abnormal velocity waveforms from the umbilical
artery, (f) known small for gestational age fetus ( < 5th
centile) ona previous
pregnancy. Outcome data were obtained from the
hospital obstetric database. Seven women were subse-
quently excluded from data analysis because of
incomplete questionnaires or unclear uterine velocity
waveforms. Overall, 100 women met the inclusion
Immediately before Doppler ultrasound, the women
completed two questionnaires. The first was a simple
questionnaire to ascertain their history of emotional
problems, major life events in the past 3 months, and
alcohol intake (none consumed more than one unit a
day). The second was the Spielberger questionnaire,
which comprises two parts measuring both state anxi-
ety and trait anxiety.17For state anxiety, subjects are
asked how they feel at the time of being questioned,
and for trait anxiety, subjects are asked how they feel
generally. Before the study, a cut off point of scores
> 40 was selected for both state anxiety and trait
We recorded the Doppler flow velocity waveforms
using an Acuson XP 10 or Sequoia ultrasound
machine (Acuson, CA, USA) with a 3.5 or 5 MHz
probe. These were later analysed by the same operator
(JT), blind to the questionnaire results. Colour Doppler
ultrasound was used to identify the main branch of the
uterine artery at its junction with the internal iliac
artery, from where we obtained blood flow velocity
waveforms. Waveforms were recorded from both uter-
ine arteries, and from the fetal middle cerebral artery
and umbilical artery in standard fashion. We derived
the resistance index for the uterine arteries (fig 1), and
the pulsatility index (A− B/mean waveform height (fig
1) for fetal vessels, from five consecutive uniform wave-
forms. The mother’s heart rate at the time of scanning
Fig 1 Uterine artery waveforms: (a) normal, (b) abnormal.
Resistance index=(A−B)/A. A notch (n) indicates particularly high
resistance to blood flow
BMJ VOLUME 31816 JANUARY 1999 www.bmj.com
was similarly derived. The presence or absence of a
notch in each uterine waveform was noted, and
subjects were considered positive if the notch was
present unilaterally. The coefficient of variation for the
repeated measurement of resistance index was 6%. All
100 women had complete Doppler ultrasound studies
of the uterine artery with full data for mean resistance
index, maximum resistance index, and notching. Only
84 women had full fetal Doppler ultrasound studies;
complete fetal Doppler data were obtained from 13/15
women with high state anxiety scores (high anxiety
group) and from 71/85 women with low state anxiety
scores (low anxiety group).
Mean resistance index was calculated as the mean
value from both left and right uterine arteries.
Maximum resistance index was the maximum of the
mean values obtained from either artery. Continuous
variables were tested for normality, and variables that
were not distributed normally were transformed
appropriately. The following tests were used as appro-
priate: Student’s t, Mann Whitney U, Fisher’s exact, and
Wilcoxon matched pairs tests. All the tests were two
In the final cohort of 100 women, the state anxiety
score was lower than the trait anxiety score: median
(range) 28.5 (20-61) versus 36 (20-67) (P < 0.001).
Fifteen women scored > 40 for state anxiety, and 32
women scored > 40 for trait anxiety.
A significant association was found between
maximum resistance index and both state anxiety
scores (rs= 0.31, P < 0.002) and trait anxiety scores
(rs= 0.28, P < 0.005), and between mean resistance
index and both state anxiety scores (rs= 0.28,P < 0.005)
and trait anxiety scores (rs= 0.21, P < 0.03). Figure 2
shows the data for maximum resistance index.
When the groups were dichotomised, using the
predetermined cut off point of a score of > 40, women
in the high state anxiety group had significantly worse
uterine velocity waveforms than those in the low state
anxiety group, whether considered as mean resistance
index, maximum resistance index, or notching (table);
mean difference in mean resistance index 24%; 95%
confidence interval 12% to 38%; P < 0.0001; and mean
difference in maximum resistance index 23%; 10% to
37%; P < 0.0005. Using trait anxiety ( > 40), there were
also differences between high and low anxiety groups
(mean difference in mean resistance index 13%; 4% to
23%; P < 0.005); and mean differences in maximum
resistance index (mean increase 16%; 6% to 26%;
P < 0.001). The 15 women who had the highest trait
anxiety scores (12 of whom also had high state anxiety
scores), had similar mean and maximum resistance
indexes to the 15 women who had high state anxiety
scores (0.56. and 0.63 respectively). Those women who
had low scores for state anxiety but high scores for trait
anxiety (n = 20) were not significantly different for
mean or maximum resistance indexes from those
women with low scores for both state anxiety and trait
anxiety (n = 65).
We also compared the two state anxiety groups for
the proportion of women with a resistance index of
0.68 or above—that is, the upper limit of the 95% refer-
ence range for a mean gestation of 32 weeks.19In the
most anxious group, 4/15 (27%) women had a mean
resistance index >0.68 compared with 3/85 (4%)
women in the less anxious group (P < 0.01) (table). Of
the seven women with mean resistance indexes >0.68,
six had high trait anxiety scores.
The group of women with a notch was overlapping
but distinct from those with a resistance index >0.68.
The group had a mean (SD) resistance index of 0.6
(0.1). The presence of a notch (unilateral or bilateral)
was associated with state anxiety; 4/15 women in the
high anxiety group had a notch compared with 4/85
women in the low anxiety group (P < 0.02). All but one
of those with a notch had high scores for either state
anxiety or trait anxiety. The remaining patient scored
20 (in effect zero) on both scales.
The best multiple regression model to predict
mean resistance index comprised state anxiety scores
(P < 0.001) and maternal heart rate (P < 0.02), whereas
to predict maximum resistance index or notching, the
best multiple regression model comprised only state
anxiety scores (P < 0.01) for both.
Uterine Doppler ultrasound characteristics in 100 mothers with either low (<40) or
high (>40) Spielberger state anxiety scores. Values are geometric means (95%
confidence intervals) unless stated otherwise
Low anxiety scores
0.47 (0.45 to 0.49)
0.51 (0.49 to 0.54)
High anxiety scores
0.58 (0.50 to 0.67)
0.63 (0.56 to 0.71)
Mean resistance index
Maximum resistance index
No (%) with mean resistance index >0.68
No (%) with notching
State anxiety score
Maximum resistance index
Trait anxiety score
Maximum resistance index
6050 40 30 2010 7080
Fig 2 Correlation between maximum resistance index and scores for
both state anxiety (rs=0.31, P=0.00180) and trait anxiety (rs=0.28,
P=0.0048) in 100 pregnant women
BMJ VOLUME 318 16 JANUARY 1999www.bmj.com
No significant differences were found in the
clinical variables studied between the high and low
anxiety groups, whether divided by state anxiety or
trait anxiety. For the mother these included age,
maternal heart rate, parity, and emotional history or
life events during this pregnancy. For the fetus they
included birth weight, estimated fetal weight and
gestational age at Doppler ultrasound, fetal heart rate,
and pulsatility index of the umbilical and middle cere-
bral artery.All subjects were normotensive ( < 120/90)
at the time of Doppler analysis. Four women
developed pre-eclampsia before delivery, all in the low
anxiety groups; one woman had a notch and high
resistance index (mean 0.7), and the other three
women had normal uterine waveforms. Six fetuses
were small for gestational age at birth. The median
mean resistance index value for these was 0.6 (range
0.42 to 0.73).
This study shows an association between anxiety and a
high resistance index whether analysed as continuous
data (fig 2) or dichotomised (table). Women with
increased anxiety are more likely to have abnormal
variables for uterine artery blood flow than those with
less anxiety, whether considered as mean resistance
index, maximum resistance index, or notching. This
association was more pronounced for state anxiety
than for trait anxiety. There were, however, more
women in the high trait anxiety group than in the high
state anxiety group.
Furthermore those women with abnormal Doppler
ultrasonograms were more likely to be anxious. All
eight women with a notch had an abnormal score on
the Spielberger questionnaire (0 scores often signify
denial and an underlying psychopathology20). In addi-
tion,6/7 women with resistance indexes >0.68—that is,
the 95th centile—had high anxiety scores, four had
high state anxiety scores, and six had high trait anxiety
Women with high state anxiety scores had slightly,
although insignificantly, faster heart rates. However,
we used multiple regression to show that the
association between mean resistance index and state
anxiety score was not a confounding effect of maternal
The 100 women we studied seem reasonably
representative of a non-selected population.Seven had
mean resistance indexes on or above the 95th centile,
eight had notches (a similar freqency to that found in a
large population study16), six had babies with birth
weights at or below the 5th centile. In the general
population about 30% of women score > 40 for both
state anxiety and trait anxiety.21We observed the same
proportion for trait anxiety scores, but not for state
anxiety scores. State anxiety scores were lower. It may
be that pregnancy in itself was relaxing, at least in the
middle of the third trimester in this cohort of women
with no obstetric complications.
The Doppler ultrasound waveforms studied here
predominantly represent downstream resistance, and
not strictly blood flow. However, assuming a relatively
stable cardiac output, they are a reasonable index of
uterine blood flow. Studies on Doppler ultrasound of
uterine arteries to predict impaired trophoblastic inva-
sion have attempted to concentrate on the side supply-
ing the placenta. In this study we have chosen to
determine the mean of the resistance indexes on both
sides of the uterus (mean resistance index), because
ascribing placentation entirely to one side is necessar-
ily artificial. As the highest resistance index (maximum
resistance index) is the more abnormal, and possibly
thus more clinically relevant, we also analysed this.
Whether mean or maximum resistance index was
used, the results were generally similar. Impaired uter-
ine blood flow is generally considered a chronic
invasion of the placenta by the trophoblast in early
pregnancy,22and abnormal patterns, either high resist-
ance indexes or notching, are predictive of pre-
eclampsia and intrauterine growth retardation.16This
does not, however, exclude later changes in uterine
blood flow, such as might be associated with transient
changes in maternal hormone concentrations, as
shown in animal models.23Indeed, exercise transiently
increases uterine resistance indexes in pregnant
women at around 34 weeks of gestation,24
treatment interventions can acutely improve blood
The hypothalamic-pituitary-adrenal axis may be
involved in the altered blood flow pattern described
here,27but an obvious candidate for mediator is
noradrenaline. High scores for state anxiety are associ-
ated with increased plasma noradrenaline concentra-
Also, infusion of noradrenaline decreases
uterine blood flow, both in pregnant sheep and
pregnant guinea pigs.23 29In fact,in sheep,reproductive
tissues (including the uterus) were more sensitive to the
vasoconstrictive effects of noradrenaline than were
other body tissues.29It may be that in times of stress the
mother has evolved to protect herself at the expense of
We do not know whether the associations between
anxiety and Doppler ultrasonograms are acute or
chronic. Although we found stronger associations for
state anxiety than for trait anxiety, the top 15% of
women with either score were largely the same
patients, and had similarly abnormal waveforms.
Further work is needed to determine whether overall
anxiety during pregnancy or even before or at concep-
tion might affect uterine artery blood flow, or instead
whether the association is only with the current
+ Women who were anxious during pregnancy
had significantly abnormal patterns of blood
flow through the uterine arteries
+ Of the most anxious group, 27% had an
increased resistance index of clinical
concern, compared with 4% in the less anxious
+ The study did not establish whether the
impaired blood flow was predominantly linked
with state anxiety or trait anxiety
+ The findings may help to explain previous
studies that have linked stress or anxiety
in pregnancy with small for gestational age
BMJ VOLUME 318 16 JANUARY 1999 www.bmj.com
emotional state. It is also possible that there is some Download full-text
underlying factor that causes both increased anxiety
and diminished trophoblastic invasion. It is unlikely
that the women in our study had reason to be
concerned about the progress of their pregnancy,as we
excluded those with pre-eclampsia or fetal growth
retardation known before Doppler ultrasound.
Although there are many contributors to fetal
growth and birth weight, reduced blood flow through
the uterine arteries could partially explain why women
who are anxious during pregnancy tend to have
smaller babies. It is also possible that this mechanism is
related to some of the findings by Barker,7 31which
have linked low birth weight to a later predisposition to
coronary heart disease.
We thank the Henry Smith Charity, the Children Nationwide
Medical Research Fund, the John Ellerman Foundation,
Caroline Doré for statistical advice,and Diana Adams for patient
analysed the raw data, and refined drafts of the paper; he will act
as guarantor for the paper. NMF refined the study design and
drafts of the paper, supervised the Doppler studies, and contrib-
uted to statistical analysis. VG originated the study, supervised
the psychometric testing, and drafted the paper.
Funding: JMAT was supported by the Calouste Gulbenkian
Conflict of interest: None.
the Doppler studies,
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RM, Zelnik T. Peripheral
(Accepted 23 October 1998)
Notice of inadvertent duplicate publication
The BMJ regrets that the paper “Diabetes mellitus and
raised serum triglyceride concentration in treated
hypertension—are they of prognostic importance?
Observational study” by O Samuelsson et al
(14 September 1996;313:660-3) was substantially
similar to a paper published in the Journal of Internal
Medicine entitled “The role of diabetes mellitus and
hypertriglyceridaemia as coronary risk factors in
treated hypertension: 15 years of follow up of
antihypertensive treatment in middle aged men in the
Primary Prevention Trial in Göteborg, Sweden”
(1994;235:217-27). The statistical evaluation is more
thorough in the BMJ paper, but the articles present
essentially the same data on the same patients.
However, we were not told of the existence of the
earlier paper, in contravention of our instructions to
authors and of internationally agreed guidelines.
Professor Samuelsson has apologised for not making
us aware of the possible duplication.
Die: The singular of dice. We seldom hear the word,
because there is a prohibitory proverb, “Never say
Ambrose Bierce, The Cynic’s Word Book (1906),
subsequently titled The Devil’s Dictionary
BMJ VOLUME 31816 JANUARY 1999www.bmj.com