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The research joins a growing number of studies exploring the use of unconventional therapies, such as psychedelics like MDMA and psilocybin , in treating various mental health conditions. The current study included a diverse sample and was a double-blind, placebo-controlled phase 3 trial. The findings are published in Nature Medicine. This particular study was built on decades of previous research. As a double-blind placebo-controlled study, it has a low risk for bias, allowing for valuable data collection. Researchers included participants with moderate or severe PTSD. Researchers divided participants into two groups: one receiving MDMA and the other receiving the placebo. A higher score on this scale indicates more severe PTSD. A higher score indicates a greater level of impairment. Among the 52 participants who received MDMA, 45 experienced clinically meaningful benefit. Overall, the treatment was also well-tolerated by participants. They affect specific receptors in the brain. Researchers are continuing to look into how psychedelics can treat medical conditions. For example, research has indicated that psychedelics may be helpful in the treatment of depression. One main area of research is using psychedelics to help treat post-traumatic stress disorder PTSD. PTSD is a mental illness that can develop after experiencing or witnessing a traumatic event. People with PTSD can experience many challenging symptoms, including distressing thoughts and flashbacks to traumatizing events. MDMA , sometimes called ecstasy or molly, is a synthetic drug with psychedelic properties. It also increases levels of dopamine , norepinephrine , and serotonin. Like other psychedelics, it can influence how people think and their perception of reality. The authors of this study note that MDMA helps eliminate fear and promote openness. MDMA promotes prosocial feelings and behavior and a sense of bonding and openness, and reduces responses to fearful or threatening stimuli. Pharmacologically, MDMA increases the release of serotonin. This research still has certain limitations. Of the participants, 74 were women, meaning other studies could include more men. There were some side effects and adverse events that participants experienced. Doctors would need to consider these potential risks if they end up using MDMA in regular clinical practice. There was some risk that expectations of treatment could have impacted results. Still, certain mitigation factors helped to minimize this risk. Researchers did exclude participants who were at high risk for suicide , had comorbid personality disorders , or had underlying cardiovascular disease. They also excluded participants who had histories of or current certain substance use disorders. Further research on how MDMA compares or combines with other treatments for PTSD could also be helpful, as well as how specific factors like gender influence treatment effectiveness. There is also the need for long-term data on the risk of people abusing or misusing MDMA after study participation. Study author Jennifer M. The FDA then has six months to review the application and render a decision. Jennifer M. For Medical News Today's In Conversation podcast for May, we delve into research on the future of mental health, with a focus on psychedelics and…. In this edition of Medical Myths, we tackle 11 myths associated with mental health and address the stigma that is wrongly linked with mental disorders. Najaf Amin and mental health advocate Rachel Kelly join Medical News Today in conversation about why and how diet might help fight symptoms of…. Learn about its uses and…. Medical News Today. News Latest News. Podcasts All 3 ways to slow down type 2 diabetes-related brain aging Toxic metals in tampons: Should you be worried? Can tattoos cause blood or skin cancer? What makes a diet truly heart-healthy? Is intermittent fasting actually bad for your heart? Newsletters Sign Up. Follow Us. Post-traumatic stress disorder PTSD is a mental health condition that can be debilitating, and its treatment often involves a combination of therapies. Research is ongoing about using psychedelics in treating mental health conditions, including PTSD. First FDA-approved psychedelic therapy? Using psychedelics for mental health. Long-term data on effects of MDMA misuse still needed. Share this article. Latest news Study detects early Alzheimer's 'stealth' phase before symptoms set in. Can standing too much be harmful to heart health? Semaglutide boosts heart health, weight loss but may lead to gut problems. Tenecteplase more likely to lead to 'excellent' stroke recovery, study finds. Mitochondria may trigger Crohn's disease by disrupting the gut microbiome. Related Coverage. In Conversation: Can psychedelics rewire a depressed, anxious brain? Medical myths: Mental health misconceptions In this edition of Medical Myths, we tackle 11 myths associated with mental health and address the stigma that is wrongly linked with mental disorders. In Conversation: Can diet help improve depression symptoms? What is MDMA therapy used for?

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Background: Question-order changes in repeated surveys can distort comparisons. We want to describe the evolution of drug risk perceptions among Spanish adolescents and assessing whether the peaks in perceived risk of occasional drug use can be explained by question-order changes. Methods: The subjects were secondary students from a biennial national survey during — A one-off intervention was applied in , replacing the two-adjacent items on perceived risk of occasional and regular use of each drug by non-adjacent items. Annual prevalence of high-risk perception were obtained for occasional and regular use of cannabis, heroin, cocaine and ecstasy. Subsequently, the percent level change PC in such were estimated prevalence using segmented Poisson regression, adjusting for various student and parent covariates. These PCs were very high in all considered subgroups. The evolution of preventive interventions does not suggest alternative causal hypotheses for peaks other than question-order changes. Conclusion: Within the cognitive heuristics framework, the spikes in perceived risk of occasional drug use were most likely due to a release of the anchor exerted by perceived risk of regular drug use over that of occasional use triggered by question-order changes. In repeated surveys it is inexcusable to pre-test the effect of any change in questionnaire format. Repeated surveys are often used to make cross-period or cross-site comparisons of health-related phenomena in both patients and population, in order to improve decision-making on health interventions. These surveys are prone to information bias that can severely limit such comparisons, due to various factors, including differences or changes in measurement instruments, particularly questionnaires. When designing survey questionnaires, most researchers know that they must keep the same question wording in different or successive measurements, but they often forget that changes in the format, ordering or clustering of the questions can strongly affect their interpretation and response 1 — 4. Changing, deleting or adding a previous question item could greatly alter the answers to the next one, even if its wording is entirely kept 5 — 12 , particularly when questionnaires include multiple question items on similar topics with identical response categories —question grids- In some self-administered question grids, a subsequent question may also affect the preceding one, because the respondent may receive both simultaneously 14 , These context or question-order effects can appear when recalling witnessed events, behaviors, tasks performance or people 7 , 11 , However, they are especially conspicuous for subjective phenomena such as perceptions, beliefs, values, preferences, attitudes or future intentions, since they are usually subject to greater uncertainty in response selection 6 , 8 — 10 , 15 , 17 — Susceptibility to order effects depends on numerous factors, including the nature and difficulty of the self-reported subject, specific questionnaire format, and respondent factors such as sex, age, education level, or direct experience on the subject 20 — However, previous evidence on the influence of these factors is often inconsistent Perceived risk of illicit drug use by adolescents is routinely monitored in many countries 33 — 35 , most of these data employed on secondary analysis on risk prevention ESTUDES is a biennial school survey on drugs aimed at secondary school students conducted in all Spain since , which uses a self-administered paper-and-pencil questionnaire, including questions on subjective judgments on risk of occasional and regular use of different illicit drugs In , the ordering and clustering of the questions on perceived risk of occasional and regular drug use was changed. In statistical analyses, sudden increases in risk perception of occasional use of all considered drugs were found in , which were suspected to be artifacts due to the aforementioned reordering of questionnaire items, so in and later editions it was decided to restore the initial questionnaire format. A national representative sample was selected in each edition through a two-stage cluster sampling procedure school and classroom The total sample size was , students, ranging from 20, to 32, in the different editions. The study is conceived as a large-scale unplanned single-group experiment, in which a one-off intervention that had not been applied between and was applied in to the entire study population and ceased to be applied in subsequent years, being analyzed the changes in a target and a control outcome over time. The intervention consisted of changing the ordering of questions on drug risk perception question-order changes , although in fact it also implies a change in their clustering. Specifically, drug risk perception had been assessed until by an adjacent item-pair model, in which the pair of questions assessing the risk perception of occasional and regular use of a given drug were consecutively presented one after the other without any intermediate question. However, the questionnaire changed in towards a non-adjacent item-pair model, in which the pair of questions mentioned for a given drug were not consecutively presented, but in two large different blocks or grids, the first referring to occasional use of all drugs and the second to regular use Table 1. Table 1. The outcomes were the perceived risk of using occasionally monthly or less frequently and regularly weekly or more frequently four illicit drugs, specifically cannabis, heroin, cocaine and ecstasy. To assess the risk perception of drug use, the respondents had to indicate the problems health or otherwise that entails each of the considered drug use behaviors using an ordinal scale of four responses no problem, few, quite a few and many Table 1. The education level and course repetition were considered as indicators of academic performance to achieve cognitive skills, and age was used as a proxy of expertise knowledge on the self-reported subject , since it is assumed that older students have received more information on drug risks prevention programs, courses, etc. In addition to the ESTUDES variables, data on annual indicators of preventive interventions were obtained from activity reports of the National Plan on Drugs 38 , in order to assess if the changes in outcomes could depend on greater magnitude of such interventions. These indicators include number of schools involved in drug prevention programs, secondary students coverage of such programs, spending index on drug prevention per secondary student and implementation of national preventive campaigns in the media. Occasional preventive activities such as talks, distribution of written materials, workshops, awareness days, contests or exhibitions are excluded. The coverage of secondary students by school drug prevention programs is the percentage of total secondary students in Spain including vocational training who participated in those programs. The spending index on drug prevention programs per secondary student was calculated by dividing the inflation-adjusted national budget for drug use prevention by the number of secondary students registered in Spain and expressing the result in relation to the year whose spending per student was assigned the value of The aforementioned budget is the sum of the budgets of the central and regional governments and with it, school and non-school drug prevention interventions are financed. After a descriptive analysis, the prevalences of high-risk perception of occasional and regular use of cannabis, heroin, cocaine and ecstasy for each edition of ESTUDES during — were obtained. Next, two multivariate approaches were used to assess the magnitude of the change in high-risk perception of drug use compared to previous and subsequent years. The second approach was to use an interrupted time series design, which was analyzed with segmented Poisson regression. This design allowed adjustment for the covariates just mentioned plus the underlying time trend 40 , Analyses were performed using Stata V. General characteristics of study participants are shown in Table 2. Table 2. The evolution of the prevalence of high-risk perception of drug use was very different for occasional and regular use Figure 1. For occasional use the prevalence followed a relatively stable trend during pre-intervention period — , it increased sharply in the intervention year , doubling their figures, and decreased again in post-intervention period — , although maintaining a slightly higher level than in — Abrupt spikes in prevalence of high-risk perception of regular drug use during were not observed. Figure 1. Spain, — High perceived risk: the student thought that a drug use behavior for example, using heroin regularly could cause many problems in health or other aspects. Regular use: using a drug weekly or more frequently. Occasional use: using a drug monthly or less frequently. The lines are shown smoothed. Like crude prevalences, the aPRs from Poisson regression models showed a very different evolution for occasional and regular drug use Table 3. Regarding occasional use, the aPR values, using as a reference the prevalence in the year , ranged 0. However, the aPRs for regular drug use showed little heterogeneity over time, ranging from 0. Table 3. Table 4. Focusing on the results of segmented Poisson regression models, a large immediate percent level increase in prevalence of high-risk perception of occasional drug use was observed in all subgroups of sex, age and academic performance and in both users and non-users of each assessed drug, except in heroin users where only a very slight non-statistically significant increase was observed. These increases were higher in women than men, although the differences were not statistically significant for cannabis. Likewise, the increases were generally greater in students with higher educational level or higher academic performance as students in the second stage of secondary education or students who had not repeated any complete annual course , except for heroin. Regarding age, no consistent results were observed for the different drugs. Thus, the magnitude of the immediate level increase increased with age for cannabis, decreased with age for heroin, and varied little for cocaine and ecstasy Table 4. The evolution of four indicators of drug prevention interventions aimed at secondary students is shown in Table 5. Table 5. Evolution of indicators on drug prevention interventions implemented by the public administration in Spain, — Three of those indicators number of schools involved in drug prevention programs, coverage of secondary students by these programs, and spending index on drug prevention per secondary student followed a similar evolution, with a significant increase between and , a relative stabilization between that year and and a subsequent rapid decrease. For example, the coverage of the school drug prevention programs went from There were annual campaigns in the general media aimed at drug prevention in —, but they disappeared in — The maximum relative interannual increases in such indicators were found in for the coverage of school drug prevention programs The relative annual increase of the different interventions ranged from The absolute maximums of these indicators were in , , and , respectively. In , after a question-order change in ESTUDES survey, there was a sudden and large increase in risk perception of occasional use of cannabis, heroin, cocaine and ecstasy among Spanish adolescents, which largely disappeared in after restoring the initial questionnaire format. These increases occurred in all sociodemographic subgroups analyzed. After assessing the evolution of preventive interventions, no sudden increases in magnitude of these interventions were identified in , which does not suggest alternative causal hypotheses for peaks in perceived risk of occasional drug use other than question-order changes. It is highly likely that the peaks in the risk perception of occasional drug use was mainly due to question-order changes for several reasons. First, it was a peak of great magnitude, located only in and that disappeared after restoring the initial questionnaire format. Second, the Poisson regression model that identified the peak was adjusted for several individual time-varying covariates to avoid confounding. Third, the segmented Poisson regression model to measure the immediate relative change in prevalence level of high-risk perception was further adjusted for the underlying linear time trend during —, which implies some control for unmeasured individual time-varying confounders that change slowly over time Fourth, the peak was identified in all sociodemographic subgroups analyzed, including those of sex, age, education level and academic performance, both in drug and non-drug users except heroin users. Fifth, the peak was almost non-existent for the perceived risk of regular drug use, considered the control outcome or negative control. Sixth, in there were no abrupt increases in magnitude of preventive drug use interventions. Thus, although had the largest budget for drug prevention during the analyzed period, no prevention indicator had in its highest annual percent increase. Although local and regional preventive drug interventions are difficult to measure, the occurrence of sudden large-scale synchronized increases in such interventions in are highly unlikely, mainly due to their partial dependence on the national budget. Finally, among adolescents an inverse relationship between drug risk perception and drug use is usually observed 43 — However, in — in Spain the apparent huge decreases in perceived risk of cannabis, cocaine and ecstasy were accompanied by decreases in annual and monthly prevalences of use of these drugs 37 , suggesting that decreases in perceived risk were not real. Taken together, the evidence suggests a causal relationship between the questionnaire change intervention and the sudden increases in perceived risk of occasional drug use outcome. Although there are several explanations on the mechanism of the question-order effects, perhaps the most accepted rely on cognitive heuristics 13 , The mental processes of answering questionnaires usually has various steps question understanding, retrieving relevant factual data from memory, integrating it into a judgment and answer selection 1 , However, when there is considerable uncertainty, as often happens with subjective phenomena such as health-related risk perceptions, especially under conditions of fatigue or disinterest, respondents often resort to heuristics or mental shortcuts to answer by reducing the cognitive burden. One of the best known is the anchoring-and-adjustment heuristic, which involves initially focusing on an anchor or reference point, which is usually the phenomenon better known, easily recalled from memory, or more salient, and then adjusting the selected answer from the anchor 49 — This heuristic aligns well with the evidence that human judgements are generally comparative 55 , and its effects are extremely ubiquitous across topics, subgroups, and settings. Specifically, in a question grid including several items on a similar topic with a similar response scale, sometimes the response to an adjacent item, which is easier to elaborate, is used by respondents as a self-generated anchor to adjust the response to another item either by reducing the difference between both responses assimilation or expanding it contrast 51 , Consequently, they would resort to anchoring heuristics, integrating the most easily available external information, which usually refers to regular drug use, since it is a very notorious and quite frequently associated behavior with social or health problems, and subsequently adjusting the response on the risk of occasional use from that reference. As indicated, the questionnaire change consisted of asking on perceived risk of occasional and regular use of a given drug using two non-adjacent items located in different blocks non-adjacent item-pair model instead of two adjacent or consecutive items as in — and — adjacent item-pairs model. The findings show a peak in perceived risk for occasional drug use but not for regular use. This suggests that in the adjacent item-pairs model, operative in years other than , the risk perception of regular drug use would act as an anchor item 57 , so that adolescents would adjust the response to the immediately preceding item on the risk of occasional use, trying to considerably reduce the risk attributed to regular use contrast effect However, in the non-adjacent item-pair model, operative in , the anchor of regular use disappears since this item is far away in another question grid, so the perceived risk of occasional drug use shoots up. In short, the peak in perceived risk of occasional drug use was most likely due to a release from the anchor exerted by the perceived risk of regular drug use. Such release would have been triggered by the change in question-order. As indicated, some respondent factors such as sex, age, education level, or direct experience on the subject 20 — 23 can modify susceptibility to question-order effects. Regarding age, our results referring to question-order effects in perceived risk of occasional drug use are mixed, since they show a greater effect among older and younger adolescents, respectively, for cannabis and heroin, and almost no effect for cocaine and ecstasy. However, there is some previous finding indicating that younger adolescents are more strongly influenced by questionnaire format and context than older adolescents Finally, the higher peaks in adolescents with higher than lower educational level or academic performance are difficult to interpret. Thus, although it is usually thought that the greater the cognitive ability of the respondent and their direct involvement or experience in a self-reported issue, the less propensity they will have for question order effects, the truth is that the previous evidence in this regard is usually inconsistent Similarly, it would be expected that the higher the educational level and academic performance of an adolescent, the greater their knowledge on drug effects and greater cognitive ability to develop independent responses without resorting to anchors. However, the evidence on susceptibility to anchoring effect according to education or intelligence level is also inconsistent 4 , 21 , 60 — The key to the inconsistencies may be that, although the anchoring heuristic can generate bias, it is also a cognitive resource which in situations of great uncertainty and time constraints helps build responses and judgments Given that this study is based on a natural experiment, its main limitation is the potential influence of uncontrolled factors changing between survey and the others. Notwithstanding, even if it cannot be completely ruled out, the role of potential unknown events social, political, communicative, etc. A detailed search has been made and no one relevant has been found. Other changes in survey methodology i. In this sense, it is a guarantee that there have not been abrupt changes in other sociodemographic indicators, drug use, opinion and perceptions from the survey. On the other hand, dissimilar results observed by drug and sociodemographic subgroup could be argued as a limitation. In fact, these findings do not match with previous knowledge concerning individual susceptibility to cognitive heuristics. However, this background is moderately inconsistent, and this study was not focused on analyzing individual differences. In general terms, the anchoring effect release in was observed among all drugs and subgroups, and just the magnitude of this fact changed from some groups to others. The findings suggest that when assessing the magnitude of a subjective health-related phenomenon subject to considerable uncertainty i. The standardization over time, space, groups and individuals of data collection methods or instruments, including questionnaires, is essential to achieve valid estimates of any health measure, particularly subjective ones, and to be able to make valid comparisons based on them. Questionnaire changes should be minimized and if unavoidable they should be carefully pretested through a cognitive interview and piloted before launching 65 , Likewise, researchers and decision makers in the health field must be aware that the comparison of findings from two questionnaires with items with the same wording but different ordering or clustering may be affected by question-order biases that invalidate such a comparison. Another important corollary is that the transfer of evidence from self-reported surveys to policies must be very careful and prudent, since the results are highly dependent on the characteristics of the data collection instrument. For this reason, it is also convenient to triangulate the results of these surveys with other sources or methods, such as qualitative techniques. The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. CP-R analyzed the data and wrote the manuscript. JoP and GB originated and designed the study and coordinated the writing of the article. JG collaborated in the bibliographic search and in the debugging of the database. ER contributed to the interpretation of the results and to the drafting of the manuscript. All authors have contributed to the work, agree to the order in which they are listed, have read and reviwed the final manuscript and approved the final version and its submission. The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher. Tourangeau, R. Cognitive sciences and survey methods In: Council NR, editor. Cognitive aspects of survey methodology: Building a bridge between disciplines. Google Scholar. Spacing, position, and order: interpretive heuristics for visual features of survey questions. Public Opin Q. Schwarz, N. Self-reports: how the questions shape the answers. Am Psychol. Generalization of classic question order effects across cultures. Sociol Methods Res. Holyk, G. Context effect In: PJ Lavrakas, editor. Encyclopedia of survey research methods. Bowling, A, and Windsor, J. 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No use, distribution or reproduction is permitted which does not comply with these terms. Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. Top bar navigation. About us About us. Sections Sections. About journal About journal. Article types Author guidelines Editor guidelines Publishing fees Submission checklist Contact editorial office. Public Health , 14 April Abrupt peaks in perceived risk of occasional drug use after changing the question order in a repeated self-administered survey. Introduction Repeated surveys are often used to make cross-period or cross-site comparisons of health-related phenomena in both patients and population, in order to improve decision-making on health interventions. Study design and variables The study is conceived as a large-scale unplanned single-group experiment, in which a one-off intervention that had not been applied between and was applied in to the entire study population and ceased to be applied in subsequent years, being analyzed the changes in a target and a control outcome over time.

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