F.D.A. Bans Three Arsenic Drugs Used in Poultry and Pig Feeds

In resolving a longstanding dispute, the Food and Drug Administration has announced that it will rescind approval for three of the four arsenic drugs that had been used in animal feeds at the request of the companies that market them.

The companies, Zoetis and Fleming Labs, already had largely withdrawn the three drugs from the market after recent studies showed levels of arsenic in chicken that exceeded amounts that occur naturally.

The compounds — roxarsone, carbarsone and arsanilic acid — have been used in 101 drugs added to feed for chickens, turkeys and pigs to prevent disease, increase feed efficiency and promote growth, according to the Center for Food Safety, which together with several other advocacy groups filed a petition almost four years ago seeking to ban the drugs in animal feeds.

"Zoetis withdrew roxarsone from the market voluntarily two years ago, and the companies have moved to withdraw the other two," said Richard Sellers, vice president for feed regulation and nutrition at the American Feed Industry Association. "Now the F.D.A. is legally withdrawing their ability to market those drugs."

The issue of arsenic in food has drawn increased public scrutiny since research last year by Consumer Reports found substantial arsenic levels in rice. Arsenic residue in rice often comes from the water used to grow it, and poultry feces are widely used as fertilizer for a variety of crops.

Pfizer, which spun its animal health division off as Zoetis this year, withdrew its roxarsone drug, 3-Nitro, from the market in 2011 after the F.D.A. found inorganic arsenic in chicken livers. "The product is no longer manufactured or used," said Ashley Peterson, vice president of scientific and regulatory affairs at the National Chicken Council. "No other feed additives containing arsenic are currently used in broiler meat production in the United States."

Nitarsone, the last of the four drugs the groups sought to ban from animal feeds, is the only known treatment for blackhead, or histomoniasis, a disease that can kill turkeys. Keith M. Williams, a spokesman for the National Turkey Federation, said nitarsone made from organic arsenic is used in the first six weeks of a turkey's 20-week life span and that there is no other known treatment.

The F.D.A. said it would continue to study the effects of nitarsone.

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Study of Hormone Use in Menopause Reaffirms Complex Mix of Risks and Benefits

Hormone therapy for menopause is one of the most divisive subjects in medicine, hailed by some as a boon to women's comfort and well-being, vilified by others as a threat to health.

A new analysis finds truth somewhere in the middle, reaffirming previous warnings that the drugs have more risks than benefits for most women — but also stating that the harms are low early in menopause and that hormones are "appropriate for symptom management in some women."

Dr. JoAnn E. Manson, the first author of the analysis and a professor of medicine at Harvard's medical school, said in an interview that the findings "should not be used as a basis for denying women treatment if they're in early menopause and have significant distressing symptoms."

The new report, published on Tuesday in The Journal of the American Medical Association, is based on long-term data from the Women's Health Initiative, a large, federally funded study that turned medical thinking on its head a decade ago by uncovering the risks of hormones.

The new report is the first to include extended follow-up data from the original health initiative study, an additional six to eight years' worth of information on about 80 percent of the original participants. They took a combination of estrogen and progesterone, estrogen alone or placebos for several years.

For combined hormones, for every 10,000 women taking the drugs, the new analysis found that there were six additional instances of heart problems, nine more strokes, nine more blood clots in the lungs and nine more cases of breast cancer. On the benefit side, there were six fewer cases of colorectal cancer, one fewer case of uterine cancer, six fewer hip fractures and one fewer death. Most of the effects wore off once the drugs were stopped, but the risk of breast cancer remained slightly elevated.

Women who took estrogen alone actually had a reduced risk of breast cancer and heart problems; the reason is not known. For other conditions, the results were similar to those for combined hormones. But estrogen alone can be given only to women who have had their uterus removed, because estrogen alone increases the risk of uterine cancer. In women who still have a uterus, the estrogen must be combined with some form of progesterone.

For both types of hormone treatments, the risks were lowest in the youngest women, ages 50 to 59, and highest in women from 70 to 79.

In 1993, when the study began, millions of women were taking the drugs to relieve hot flashes and vaginal dryness. There was also a widespread belief that hormones would keep women youthful and feminine, and prevent heart disease and dementia.

The study, which included more than 27,000 women age 50 to 79, provided a rude shock: it found that hormones might actually cause the ailments they were thought to prevent. The most popular treatment, the combined hormones, increased the risk of heart disease, breast cancer, blood clots, strokes, gallstones, urinary incontinence and dementia. Another treatment, estrogen alone — given only to women who had surgery to remove the uterus — also increased the risk of blood clots, strokes, gallstones and urinary incontinence.

Hormone use dropped sharply after the findings came out in 2002. But some doctors and patients stuck with the drugs, arguing that the risks were relatively small and had been overplayed, needlessly frightening women away from the best treatment for hot flashes, night sweats, insomnia and vaginal dryness that can take the joy out of sex.

A few years after the findings came out, the incidence of breast cancer in older women dropped significantly, something that statisticians attributed to the decline in hormone use.

Dr. Elizabeth G. Nabel, a professor of medicine at Harvard who wrote an editorial accompanying the new report, said in an interview that seemingly small risks could be significant for individual patients, particularly people with family histories of breast cancer, heart disease or strokes.

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Well: Breast-Feeding Services Lag Behind the Law

Under the Affordable Care Act, insurance companies are required to pay for breast pumps and counseling for new mothers to address breast-feeding problems. The aim is to encourage more women to breast-feed so their infants can reap the health benefits, including reduced risks of asthma, leukemia and Type 2 diabetes.

"First efforts at breast-feeding are not as intuitive as it seems," said Dr. Linda Rosenstock, chairwoman of the Institute of Medicine's committee on preventive services for women, adding, "Some women need additional professional support so they do it well and continue to do it."

Despite the law, many new mothers have found it nearly impossible to get timely help for breast-feeding problems since Jan. 1, when health insurers began updating their coverage. While a 2011 Surgeon General's report hailed lactation consultants as important specialists, few insurers have added them to their networks.

Some insurers simply point women to pediatricians not necessarily trained in lactation. Even then, women often must locate help on their own, leading to delays that jeopardize a mother's milk supply.

Breast-feeding advocates fear this mandate is falling victim to bureaucratic foot-dragging, cost-saving and ambivalence.

"It's abysmal, the state of lactation services being provided by insurance companies currently," said Susanne Madden, a founder of the National Breastfeeding Center, which last month published an unsettling assessment of the breast-feeding policies of insurers nationwide. Twenty-eight out of 79 received D's or F's.

New mothers face a number of obstacles in breast-feeding, including insufficient milk or a painful infection. Problems must be resolved quickly: when a baby is hungry, there is little time to wrangle with an insurer over payment for a breast pump or a lactation consultant. A delay can mean that mothers turn to formula, don't establish an adequate supply, or quit.

In August, when her son had trouble latching, Maryanne Conte, 40, called her insurer, Blue Cross Blue Shield Illinois. Time was of the essence, as her doctor said the baby was failing to thrive.

A customer representative confirmed that lactation consultations were covered, Ms. Conte said, but could not name anyone in-network nearby or confirm coverage for the consultant her pediatrician had recommended. She paid $240 out of pocket for a house call from that consultant, and with some assistance, her son opened his jaw wider to feed more effectively and her milk production increased. Two months postpartum, she is exclusively breast-feeding.

But Blue Cross Blue Shield Illinois would not reimburse the fee. "I don't understand how an insurer can get away with denying lactation consultations that they are required to provide," said Jonathan Conte, 31, her husband.

Mary Ann Schultz, a spokeswoman for the insurer, said Ms. Conte's specialist did not have "state-recognized certification," and so would not be covered. She said Ms. Conte had been told as much. After reviewing the call notes, Ms. Schultz also said Ms. Conte never asked for providers in Brooklyn, where she lives.

The Health and Human Services Department says insurers cannot deny lactation services simply because they lack trained providers in-network; they are obligated to cover one out of network. An unreasonable delay is also not acceptable.

"We are committed to working with insurers and consumers to ensure that women receive the benefits they are entitled to under the law," said Joanne Peters, a spokeswoman for the department.

Jessica Lang Kosa, a lactation consultant in Newton, Mass., says some mothers are sent on wild goose chases. Their insurers tell them to find a consultant certified by the International Board of Lactation Consultant Examiners, then to call back to check if that person's services are covered.

But it's "an exercise in futility," Ms. Kosa said, because the insurer often has no such lactation consultants as providers.

Aetna is a notable exception. The insurer has lactation consultants in-network, and it covers out-of-network consultants.

But other insurers advise women to get help from an in-network ob-gyn or a pediatrician. "It's the lactation visits that many insurers are not covering, the face-to-face clinical evaluation by somebody who can provide a higher level of care," said Marsha Walker, of the U.S. Lactation Consultant Association. "A physician doesn't have the time and, a lot of times, does not have the training to do this."

Just as the health care act doesn't specify what kind of breast pump insurers have to furnish, it doesn't say who qualifies as a "trained provider" of lactation counseling.

Tamara Hawkins, a nurse practitioner and lactation consultant in Manhattan, said, "I don't think they will be able to justify they are giving women the help they need without bringing on specialized lactation consultants."

The law does permit insurers to require that providers be state-licensed in order to be included in an insurer's network. Lactation consultants are not currently licensed by states, but now some are pushing for it.

Frustrated, some mothers have also complained to their state insurance commissioners, according to the National Association of Insurance Commissioners, or turned to advocacy groups.

"It's not surprising insurance companies are saying no," said Judy Waxman, of the National Women's Law Center. "We have to keep pushing them and educating them and telling them what the law really says."

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Well: How Intense Study May Harm Our Workouts

Phys Ed

Gretchen Reynolds on the science of fitness.

Tire your brain and your body may follow, a remarkable new study of mental fatigue finds. Strenuous mental exertion may lessen endurance and lead to shortened workouts, even if, in strict physiological terms, your body still has plenty of energy reserves.

Scientists have long been intrigued by the idea that physical exertion affects our ability to think, with most studies finding that short bouts of exercise typically improve cognition. Prolonged and exhausting physical exercise, on the other hand, may leave practitioners too worn out to think clearly, at least for a short period of time.

But the inverse possibility — that too much thinking might impair physical performance — has received far less attention. So scientists from the University of Kent in England and the French Institute of Health and Medical Research, known as INSERM, joined forces to investigate the matter. For a study published online in May in Medicine & Science in Sports & Exercise, they decided to tire volunteers' brains with a mentally demanding computer word game and see how well their bodies would perform afterward.

Fatigue is a complex, multifaceted condition. Exercise science usually concentrates on bodily fatigue, meaning a reduction in our ability to contract muscles and stay in motion. Run, cycle, lift weights or just stand, and a small army of muscles contract, burning fuel and eventually tiring. This fatigue occurs both within the individual muscles and at the level of the nervous system, a condition known as central fatigue.

Our minds tire, too, although the causes are difficult to pin down. Neurons may run low of fuel, and other processes probably also are involved. But it is clear, as many of us know from personal experience, that concentrating intensively on an intellectually demanding project for hours typically leaves you feeling mentally dull.

To determine the impact that such mental fatigue might have on subsequent exercise, the researchers first asked 10 healthy, active young men to visit an exercise lab on several occasions. During each visit, the men began by having monitors and an electrode attached to one leg and then vigorously contracting their leg muscles, while the electrode zapped a small amount of electricity into the muscles, augmenting their effort so that they reached their maximum contractile force at that moment. Tired muscles would be expected to produce less force and respond more feebly to the electrical zapping, telling scientists to what degree the body has developed both localized and central fatigue.

Then, during one session, the men sat for 90 minutes before a computer screen, intently watching individual letters flash by while they counted every four and punched various keys, depending on how each grouping of the letters was configured. This test is known reliably to induce mental fatigue.

During a separate lab visit, the men watched "Earth," a serene, calming documentary, for 90 minutes.

After both intellectual activities, the men exercised one of their legs at a specialized one-legged ergometer to the point of muscular exhaustion, while frequently telling the researchers how strenuous the exercise felt.

Then they underwent the test of actual maximum contractile force one more time.

As it turned out, mental fatigue significantly affected the men's endurance. They tired about 13 percent faster after the computer test than after watching "Earth." They also reported that the workout felt far more taxing.

But, interestingly, their maximum contractile force was about the same after each session. Their muscles responded just as robustly to orders from the brain and the attached electrode after the draining mental workout as after the quiet session, even though the brain-fogged volunteers felt as if their muscles were much more exhausted.

This finding suggests "that maximal force production is not altered by mental fatigue but endurance performance is altered, and this alteration is closely linked with a higher feeling of perceived exertion," said Romuald Lepers, a professor at the INSERM research laboratory at the University of Burgundy in France and, with Samuele M. Marcora and Benjamin Pageaux of the University of Kent, co-author of the study.

In simpler terms, exercise simply feels harder when your brain is tired, so you quit earlier, although objectively, your muscles are still somewhat fresh.

This finding has multiple implications for how we combine ratiocination and sweat. It suggests, for instance, that the morning of an important race or challenging training session may not be the ideal time to finish your taxes, since overthinking could lead to underperforming physically.

Inversely, the results also suggest that "training our brain to avoid or limit mental fatigue" could be a hitherto untapped means of improving physical performance, Dr. Lepers said. Training yourself to speed through crossword puzzles, in other words, might improve your workouts, by subtly altering how mind and muscles communicate and making your brain less likely to consider your muscles easily enfeebled.

But that possibility hasn't been tested, Dr. Lepers said. For now, his study's most compelling conclusion is that, as he says, "our feelings do not always reflect our physiological state" and our bodies may in many instances be sturdier than own minds realize, an idea worth thinking about.

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Letters: It May Only Look Like Shyness (1 Letter)

TO THE EDITOR:

Re "To Help a Shy Child, Listen" (18 and Under, Sept. 17): Selective mutism is an anxiety-based condition that can be confused with shyness. These children do not talk in uncomfortable situations — often in school, but sometimes even with family members and elsewhere. Those with selective mutism can go an entire school year — or years — without uttering a word. They aren't holding back willfully; they can't help it.

A coordinated care plan is needed for these children, and teachers need to be counseled on how to help a student with selective mutism. It's a long, slow process that takes an emotional toll on the family. My daughter was diagnosed at age 3 and with gradual progress is now beginning to "normalize" at age 6.

Susan Cutrofello Miele

Bronxville, N.Y.

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Letters: Best Interests of the Patient (1 Letter)

TO THE EDITOR:

Re "Easing a Difficult Passage" (Books, Sept. 24): Abigail Zuger has focused attention on a medical dilemma that affects increasing numbers of older people. I work with patients and their families who are confronting end-of-life decisions, and I recognize the impulse among some physicians to wage a relentless war against death, seemingly unaware of the cost in suffering to both patient and family.

In military affairs, we recognize that civilian authority must prevail if the expectations of generals exceed what can reasonably be accomplished. So, too, a patient or patient's family must have the final say if a physician's efforts to win the war against death ignore the wishes or best interests of the patient.

Faced with overzealous efforts, we must realize, with Swinburne, "that even the weariest river winds somewhere safe to sea."

Peter Rogatz, M.D.

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Well: Breast-Feeding Services Lag the Law

Under the Affordable Care Act, insurance companies are required to pay for breast pumps and counseling for new mothers to address breast-feeding problems. The aim is to encourage more women to breast-feed so their infants can reap the health benefits, including reduced risks of asthma, leukemia and Type 2 diabetes.

"First efforts at breast-feeding are not as intuitive as it seems," said Dr. Linda Rosenstock, chairwoman of the Institute of Medicine's committee on preventive services for women, adding, "Some women need additional professional support so they do it well and continue to do it."

Despite the law, many new mothers have found it nearly impossible to get timely help for breast-feeding problems since Jan. 1, when health insurers began updating their coverage. While a 2011 Surgeon General's report hailed lactation consultants as important specialists, few insurers have added them to their networks.

Some insurers simply point women to pediatricians not necessarily trained in lactation. Even then, women often must locate help on their own, leading to delays that jeopardize a mother's milk supply.

Breast-feeding advocates fear this mandate is falling victim to bureaucratic foot-dragging, cost-saving and ambivalence.

"It's abysmal, the state of lactation services being provided by insurance companies currently," said Susanne Madden, a founder of the National Breastfeeding Center, which last month published an unsettling assessment of the breast-feeding policies of insurers nationwide. Twenty-eight out of 79 received D's or F's.

New mothers face a number of obstacles in breast-feeding, including insufficient milk or a painful infection. Problems must be resolved quickly: when a baby is hungry, there is little time to wrangle with an insurer over payment for a breast pump or a lactation consultant. A delay can mean that mothers turn to formula, don't establish an adequate supply, or quit.

In August, when her son had trouble latching, Maryanne Conte, 40, called her insurer, Blue Cross Blue Shield Illinois. Time was of the essence, as her doctor said the baby was failing to thrive.

A customer representative confirmed that lactation consultations were covered, Ms. Conte said, but could not name anyone in-network nearby or confirm coverage for the consultant her pediatrician had recommended. She paid $240 out of pocket for a house call from that consultant, and with some assistance, her son opened his jaw wider to feed more effectively and her milk production increased. Two months postpartum, she is exclusively breast-feeding.

But Blue Cross Blue Shield Illinois would not reimburse the fee. "I don't understand how an insurer can get away with denying lactation consultations that they are required to provide," said Jonathan Conte, 31, her husband.

Mary Ann Schultz, a spokeswoman for the insurer, said Ms. Conte's specialist did not have "state-recognized certification," and so would not be covered. She said Ms. Conte had been told as much. After reviewing the call notes, Ms. Schultz also said Ms. Conte never asked for providers in Brooklyn, where she lives.

The Health and Human Services Department says insurers cannot deny lactation services simply because they lack trained providers in-network; they are obligated to cover one out of network. An unreasonable delay is also not acceptable.

"We are committed to working with insurers and consumers to ensure that women receive the benefits they are entitled to under the law," said Joanne Peters, a spokeswoman for the department.

Jessica Lang Kosa, a lactation consultant in Newton, Mass., says some mothers are sent on wild goose chases. Their insurers tell them to find a consultant certified by the International Board of Lactation Consultant Examiners, then to call back to check if that person's services are covered.

But it's "an exercise in futility," Ms. Kosa said, because the insurer often has no such lactation consultants as providers.

Aetna is a notable exception. The insurer has lactation consultants in-network, and it covers out-of-network consultants.

But other insurers advise women to get help from an in-network ob-gyn or a pediatrician. "It's the lactation visits that many insurers are not covering, the face-to-face clinical evaluation by somebody who can provide a higher level of care," said Marsha Walker, of the U.S. Lactation Consultant Association. "A physician doesn't have the time and, a lot of times, does not have the training to do this."

Just as the health care act doesn't specify what kind of breast pump insurers have to furnish, it doesn't say who qualifies as a "trained provider" of lactation counseling.

Tamara Hawkins, a nurse practitioner and lactation consultant in Manhattan, said, "I don't think they will be able to justify they are giving women the help they need without bringing on specialized lactation consultants."

The law does permit insurers to require that providers be state-licensed in order to be included in an insurer's network. Lactation consultants are not currently licensed by states, but now some are pushing for it.

Frustrated, some mothers have also complained to their state insurance commissioners, according to the National Association of Insurance Commissioners, or turned to advocacy groups.

"It's not surprising insurance companies are saying no," said Judy Waxman, of the National Women's Law Center. "We have to keep pushing them and educating them and telling them what the law really says."

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City Unveils Campaign to Improve Girls’ Self-Esteem

Mr. Bloomberg is taking on the popular, unattainable notions of beauty promoted by professional image-makers with a campaign that tells girls that they are beautiful the way they are.

Mainly through bus and subway ads, the campaign aims to reach girls from about 7 to 12 years old, who are at risk of negative body images that can lead to eating disorders, drinking, acting out sexually, suicide and bullying. But unlike Mr. Bloomberg's ads to combat teenage pregnancy, smoking and soda-drinking, which are often ugly, revolting or sad, these ads are uniformly upbeat and positive.

"I'm a girl. I'm funny, playful, daring, strong, curious, smart, brave, healthy, friendly and caring," one ad, featuring DeVoray Wigfall, a robust, laughing 12-year-old from University Heights in the Bronx, says. The ads show girls of different races and sizes, some playing sports and one in a wheelchair. Each one ends with the campaign's overall slogan: "I'm beautiful the way I am."

City officials and experts in adolescent health said it was the first campaign aimed at female body image that they knew of to be carried out by a major city. Ads began going up on buses and in subways on Monday.

The $330,000 campaign, called NYC Girls Project, will also offer physical fitness classes for girls through the parks department, a pilot program addressing self-esteem issues for girls at 75 after-school programs, and a Twitter campaign, #ImAGirl.

A 30-second video will be shown in taxis, on YouTube and on the campaign's Web site, which will offer resources for parents and girls.

The Paley Center for Media, in partnership with the city and Spark Movement, which works against the sexualization of women in media, has developed related programs that look at the representation of girls on television.

Christopher Ochner, a researcher of obesity, eating disorders and nutrition at Mount Sinai Adolescent Health Center in Manhattan, said the ads could be effective because they offered a more realistic picture than "the media's portrayal of ideal beauty, which is still this stick-thin, crazy-thin" standard. Average girls, he added, look at fashion models and say, " 'If I'm not like that, then nobody's going to need me or love me.' "

City officials cited evidence in The American Journal of Maternal/Child Nursing and elsewhere that more than 80 percent of 10-year-old girls are afraid of being fat, that girls' self-esteem drops at age 12 and does not improve until 20, and that that is tied to negative body image.

The campaign was conceived by an aide to Mr. Bloomberg, Samantha Levine, 38, the mayor's deputy press secretary, who is serving as project director. Ms. Levine said she had been moved by stories of little girls wearing body-shaping undergarments and getting plastic surgery to improve their appearance. She said she had also been galvanized by reading the advice columnist Cheryl Strayed, who said a failure of feminism was that women still worried about what their buttocks looked like in jeans.

"I think being a woman in this society, it's sort of impossible to not be aware of the pressures there are around appearance, around weight, around trying to always look a certain way," Ms. Levine said.

The idea so resonated among her colleagues that all 21 girls pictured in the campaign are the daughters of city workers, friends and friends of friends, who believed it was important to participate. None are professional models. All but one, who lives on Long Island, live in New York City, she said.

DeVoray, the girl in one of the ads, who aspires to be either police commissioner or the first black female president, said in an interview on Monday that some of her friends asked her if they were pretty. "I say you're beautiful even if somebody tells you you're not," she said. "You have to keep your head up, don't let anybody bring you down."

Her mother, Twanna Cameron, a project coordinator for NYC Service, the agency that promotes volunteering, said she had eagerly stepped forward for the campaign. "I think every mom has those worries," she said. "We can't all be models, we can't all be superthin."

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U.S. Plans to Unveil New Insurance Options

WASHINGTON — The Obama administration plans on Monday to announce scores of new health insurance options to be offered to consumers around the country by the Blue Cross and Blue Shield Association and the United States Office of Personnel Management, the agency that arranges health benefits for federal employees, according to administration officials.

The options are part of a multistate insurance program that Congress authorized in 2010 to increase options for consumers shopping in the online insurance markets scheduled to open on Tuesday.

Congress conceived multistate plans as an alternative to a pure government-run insurance program — the "public option" championed by liberal Democrats and opposed by Republicans in 2009-10.

"The multistate program will help deliver choice and high-value health plans in the new marketplace, expanding quality, affordable options for uninsured Americans," an administration official said.

The administration plans to unveil the program on Monday, the official said, even as Congress fights over the future of President Obama's health care law, intended to provide coverage to more than 25 million people within three years.

Federal officials said they had signed a contract with the Blue Cross and Blue Shield Association to offer health insurance next year in the marketplaces, or exchanges, of 30 states and the District of Columbia. In later years, the officials said, they hoped to see at least two multistate plans in every state, as Congress envisioned.

Under its federal contract, Blue Cross and Blue Shield will offer different products in different states — a total of more than 150 products, including health maintenance organizations and preferred provider organizations, which give discounts for using selected health care providers. In many of the products, consumers will have access to a nationwide network of doctors and hospitals.

The federal government negotiated the benefits and premiums for the Blue Cross and Blue Shield products, so this plan carries a federal seal of approval.

In negotiating with insurers, the Office of Personnel Management leveraged more than 50 years of experience in the Federal Employees Health Benefits Program, the nation's largest employer-sponsored health insurance program, covering more than eight million federal employees, retirees and dependents. Blue Cross and Blue Shield plans are, by far, the most popular among federal employees, with more than 60 percent of the enrollment.

Under the 2010 health care law, the federal government was supposed to sign contracts with at least two multistate plans. But the application from Blue Cross and Blue Shield was the only one approved. Five other companies expressed interest and may file applications in the future, federal officials said. By 2017, at least two multistate plans are supposed to be available in each state.

When Congress was debating the health care legislation in 2009, many Democrats wanted the federal government to offer an insurance plan like Medicare, to compete directly with private insurers in the exchanges. In a letter to Congress in June 2009, Mr. Obama said: "I strongly believe that Americans should have the choice of a public health insurance option operating alongside private plans. This will give them a better range of choices, make the health care market more competitive and keep insurance companies honest."

Republicans resisted the idea, as did the American Medical Association and many drug companies, which feared that a government-run insurance program could set prices and drive private insurers from the market.

Supporters of the multistate plans authorized by Congress say the plans will increase competition in local health insurance markets, many of which are dominated by one or two carriers. The multistate plan will, for example, be available next year in New Hampshire and West Virginia, which would otherwise have just one carrier in their exchanges.

Federal officials said the multistate plan would also be in operation next year in Alaska, Arkansas, California, Colorado, Delaware, Georgia, Illinois, Indiana, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Missouri, Montana, Nevada, New Mexico, New York, Oklahoma, Pennsylvania, South Carolina, Tennessee, Texas, Virginia, Washington and Wisconsin.

Local Blue Cross and Blue Shield plans have been selling insurance for decades, but federal officials said the national plan would offer consumers different products and additional choices.

The multistate plan was also supposed to offer insurance to small businesses, but federal officials said it would provide such coverage next year only in Alaska, Maryland, Virginia and the District of Columbia.

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Op-Ed Contributor: Psychotherapy’s Image Problem

PROVIDENCE, R.I. — PSYCHOTHERAPY is in decline. In the United States, from 1998 to 2007, the number of patients in outpatient mental health facilities receiving psychotherapy alone fell by 34 percent, while the number receiving medication alone increased by 23 percent.

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This is not necessarily for a lack of interest. A recent analysis of 33 studies found that patients expressed a three-times-greater preference for psychotherapy over medications.

As well they should: for patients with the most common conditions, like depression and anxiety, empirically supported psychotherapies — that is, those shown to be safe and effective in randomized controlled trials — are indeed the best treatments of first choice. Medications, because of their potential side effects, should in most cases be considered only if therapy either doesn't work well or if the patient isn't willing to try counseling.

So what explains the gap between what people might prefer and benefit from, and what they get?

The answer is that psychotherapy has an image problem. Primary care physicians, insurers, policy makers, the public and even many therapists are largely unaware of the high level of research support that psychotherapy has. The situation is exacerbated by an assumption of greater scientific rigor in the biologically based practices of the pharmaceutical industries — industries that, not incidentally, also have the money to aggressively market and lobby for those practices.

For the sake of patients and the health care system itself, psychotherapy needs to overhaul its image, more aggressively embracing, formalizing and promoting its empirically supported methods.

My colleague Ivan W. Miller and I recently surveyed the empirical literature on psychotherapy in a series of papers we edited for the November edition of the journal Clinical Psychology Review. It is clear that a variety of therapies have strong evidentiary support, including cognitive-behavioral, mindfulness, interpersonal, family and even brief psychodynamic therapies (e.g., 20 sessions).

In the short term, these therapies are about as effective as medications in reducing symptoms of clinical depression or anxiety disorders. They can also produce better long-term results for patients and their family members, in that they often improve functioning in social and work contexts and prevent relapse better than medications.

Given the chronic nature of many psychiatric conditions, the more lasting benefits of psychotherapy could help reduce our health care costs and climbing disability rates, which haven't been significantly affected by the large increases in psychotropic medication prescribing in recent decades.

Psychotherapy faces an uphill battle in making this case to the public. There is no Big Therapy to counteract Big Pharma, with its billions of dollars spent on lobbying, advertising and research and development efforts. Most psychotherapies come from humble beginnings, born from an initial insight in the consulting office or a research finding that is quietly tested and refined in larger studies.

The fact that medications have a clearer, better marketed evidence base leads to more reliable insurance coverage than psychotherapy has. It also means more prescriptions and fewer referrals to psychotherapy.

But psychotherapy's problems come as much from within as from without. Many therapists are contributing to the problem by failing to recognize and use evidence-based psychotherapies (and by sometimes proffering patently outlandish ideas). There has been a disappointing reluctance among psychotherapists to make the hard choices about which therapies are effective and which — like some old-fashioned Freudian therapies — should be abandoned.

There is a lot of organizational catching up to do. Groups like the American Psychiatric Association, which typically promote medications as treatments of first choice, have been publishing practice guidelines for more than two decades, providing recommendations for which treatments to use under what circumstances. The American Psychological Association, which promotes psychotherapeutic approaches, only recently formed a committee to begin developing treatment guidelines.

Professional psychotherapy organizations also must devote more of their membership dues and resources to lobbying efforts as well as to marketing campaigns targeting consumers, primary care providers and insurers.

If psychotherapeutic services and expenditures are not based on the best available research, the profession will be further squeezed out by a health care system that increasingly — and rightly — favors evidence-based medicine. Many of psychotherapy's practices already meet such standards. For the good of its patients, the profession must fight for the parity it deserves.

Brandon A. Gaudiano is a clinical psychologist and assistant professor of psychiatry and human behavior at the Alpert Medical School at Brown University.

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