Regular Article Mental Health and Substance Abuse Spending by Age, 2003 Tami L. Mark, PhD, MBA Henrick J. Harwood David C. McKusick, PhD Edward C. King Rita Vandivort-Warren, MSW Jeffrey A. Buck, PhD Abstract This article presents national estimates of mental health and substance abuse (MHSA) spending in 2003 by age groups. Overall, $121 billion was spent on MHSA treatment across all age groups in 2003. Of the total $100 billion spent on MH treatment, about 17% was spent on children and adolescents, 68% on young and mid-age adults, and 15% on older adults. MH spending per capita by age was $232 per youth, $376 per young and mid-age adult, and $419 per older adult. Of the total $21 billion spent on SA treatment, about 9% was spent on children and adolescents, 86% on adults ages 18 through 64, and 5% on older adults age 65 and older. SA spending per capita by age was $26 per youth, $98 per mid-age adult, and $28 per older adult. Introduction Mental illness and substance use conditions can impact people at any age from the very young to those at older ages. These conditions may have varying manifestations, prevalence rates, treatment approaches, costs, and treatment 001nancing sources at different ages. The Substance Abuse and Mental Health Services Administration (SAMHSA) has been producing estimates of national Address correspondence to Tami L. Mark, PhD, MBA, Thomson Healthcare, 4301 Connecticut Avenue, NW Suite 330, Washington, DC 20008, USA. Phone: +1-301-2142211; Fax: +1-301-5308698. Email: Tami.Mark@thomson.com. Henrick J. Harwood, The Lewin Group, Inc, 3130 Fairview Park Drive, Suite 800, Falls Church, VA 22042, Canada. David C. McKusick, PhD, Actuarial Research Corporation, 5513 Twin Knolls Road, Suite 213, Columbia, MD 21045, USA Edward C. King, Actuarial Research Corporation, 6928 Little River Turnpike, Suite E, Annandale, VA 22003, USA. Rita Vandivort-Warren, MSW, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Lane, Rockville, MD 20857, USA. Jeffrey A. Buck, PhD, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Lane, Rockville, MD 20857, USA. Journal of Behavioral Health Services & Research , 2008. c) 2008 National Council for Community Behavioral Healthcare. Mental Health and Substance Abuse Spending by Age, 2003 MARK et al. spending on mental health and substance abuse treatment at regular intervals. This article parses these national estimates for 2003 into spending by age groups and is an update to an earlier effort, which examined mental health and substance abuse spending in 1997.1 Other than the earlier SAMHSA age estimates, there has been little prior data compiled on spending or use of mental health or substance abuse service by age. Zuvekas2 found that, in 1996, the percent using ambulatory mental health and substance abuse services was highest in the young and middle age adults, and lowest in the 65 and over population: 6 226 17: 6.2%; 18 226 44: 7.4%; 45 226 64: 7.3%; 65+: 5.2%.2 The number of visits per user followed a similar pattern in these age groups: 6 226 17: 6.9 visits; 18 226 44: 10.8 visits; 45 226 64: 8.4 visits; 65+: 5.1 visits. In contrast, the percent using psychotropic medications increased with age: 6 226 17: 4.1%; 18 226 44: 5.0%; 45 226 64: 8.3%; 65+: 9.1%. There was a somewhat different variation in the amount spent on psychotropic drugs per person by age group, with the lowest spending in the oldest age group: 6 226 17: $318; 18226 44: $411; 45 226 64: $339; 65+: $228. Ringel and Sturm estimated mental health treatment expenditures on children in 1998 to be $11.68 billion ($172 per child).3 Adolescents had the highest expenditures at $293 per child followed by $163 per child aged 6 to 11 and $35 per preschool-aged child. Outpatient services accounted for 57% of the total, inpatient for 33%, and psychotropic medications for 9% of the total. The goal of this study is to document US spending for mental health and substance abuse treatment in 2003 for three age groups: children and adolescents (younger than age 18), young and mid-age adults (age 18 226 64), and older adults (age 65 and older). Estimates are presented overall and by provider and service type. Methods The approach taken to estimate national mental health and substance abuse (MHSA) spending is designed to be consistent with the National Health Expenditure Accounts (NHEA). The NHEA constitute the framework from which the estimates of spending for all health care are constructed by the Centers for Medicare and Medicaid Services. Two basic methods are used to estimate MHSA treatment expenditures, depending on provider or service type. The 001rst method relies on the SAMHSA 222 s national surveys of specialty MHSA organizations. These surveys are the Survey of Mental Health Organizations (SMHO), formerly called the Inventory of Mental Health Organizations, and the National Survey of Substance Abuse Treatment Services (N-SSATS, formerly referred to as the Uniform Facilities Data Set). The surveys provide data on total revenues by type of specialty MHSA provider. The second basic method carves out spending on MHSA from the NHEA. Services and providers not fully covered in the N-SSATS or SMHO but covered in the NHEA are general hospital care outside of psychiatric specialty un its, physicians, other professionals, retail prescription drugs, nursing homes, and home health agencies. Estimates for these services are based on NHEA estimates of total spending by provider and payer. The proportion of that total spending allocated to MHSA is estimated mainly using numerous public-use, nationally representative, provider-based data sets, such as the National Ambulatory Medical Care Survey (NAMCS) and the Healthcare Cost and Utilization Project Nationwide Inpatient Sample. Allocations to MHSA typically involve 001rst determining the proportion of total service utilization (e.g., inpatient days) that involve a primary MHSA disorder, then adjusting for differences in average charges and cost sharing. For example, if the NAMCS indicated that 10% of visits to physicians were for patients with a primary MHSA diagnosis and MHSA average physician prices were 50% lower than prices of all diagnoses, then we could calculate that 5% of total national spending on physicians was for treating MHSA conditions. The determination of use and prices for particular age groups was based on patient age as indicated in the various data sets. Although estimates were created for the year 2003, the surveys used to assign expenditures to MHSA conditions by age group had relatively small sample sizes, The Journal of Behavioral Health Services & Research 2008 and there was substantial variation in year to year estimates. Therefore, utilization and price data from the year 1997 through 2004 were combined and applied to the 2003 NHEA to create the 2003 estimates. The two methods 227 the SAMHSA survey and NHEA methods 227 were integrated by adding expenditures by provider after eliminating duplication across data sources. To de 001 ne MHSA disorders, we rely on diagnostic codes listed in the International Classi 001 cation of Diseases 9th Revision (ICD-9-CM) as 223 mental disorders 224 (i.e., codes in sections 290 through 319). These codes exclude 223 cerebral degenerations 224 (e.g., Alzheimer 222 s disease, ICD-9 331.0). We also exclude several other codes related to dementia, as well as developmental delays, mental retardation, and tobacco abuse. The allocation to MHSA is based on principal or primary diagnoses. The diagnostic categories selected generally re 002 ect what payers consider as MHSA conditions. They exclude costs not directly related to mental illness or substance abuse treatment, such as disability- related costs or cost of prevention efforts. They also exclude expenditures on non-MHSA conditions that are caused by MHSA problems, such as complications from intentional injuries. The only category of service that is not allocated to MHSA based on diagnosis is retail prescription drugs. Expenditures are considered for MHSA treatment if the medication 222 s primary indication is a MHSA disorder. Findings MHSA 001ndings Overall, $121 billion was spent on MHSA treatment across all age groups in 2003 (Table 1 ). About 16% was spent on treatment of youth, 71% on young to mid-age adults, and 13% on older adults (Table 1 ). As a percent of all disease health care spending by age, 9.3% of youth spending, 11.1% of adult spending, and 3.1% of older adult spending were for MHSA treatment. Overview Mental health spending Of the total $100 billion spent on MH treatment in 2003, about 17% was spent on children and adolescents, 68% on young and mid-age adults, and 15% on older adults (Table 1 ). In 2003, there were 73 million youth under age 18, 181.9 million adults ages 18 through 64, and 36.0 million older adults age 65 or older ( http://www.census.gov ). Overall, MH spending per US resident was $345 in 2003. MH spending per capita by age was $232 per youth, $376 per young and mid-age adult, and $419 per older adult (Table 1 ). Substance abuse spending Of the total $21 billion spent on SA treatment in 2003, about 9% was spent on children and adolescents, 86% on adults ages 18 through 64, and 5% on adults ages 65 and older (Table 1 ). Overall, SA spending per US resident was $71 in 2003. SA spending per capita by age was $26 per youth, $98 per mid-age adult, and $28 per older adult. Youth less than 18 years of age: spending by provider Mental health spending Multiservice Mental Health Organizations (MSMHOs) received the largest share of MH treatment spending on youth, amounting to 30% of the $17 billion spent on youth MH treatment in 2003 (Table 2 ). This was a much larger share than was spent on young and mid-age adults. MSMHOs are freestanding MH specialty providers other than hospitals, such as clinics and residential centers. Approximately 26% of youth spending on MH was for hospital treatment: 16% Mental Health and Substance Abuse Spending by Age, 2003 MARK et al. Tabl e 1 Aggregate and per capita ment al healt h and substance abuse spendi ng in 2003: amoun ts and percentages by age group and spendi ng type Age gr oups Children and adolescents Young and Older adults (less than mid-age adults (65 years Spending type All ages 18 years) (1822664 years) and older) Aggregate spending in millions All MHSA $121,062 $18,800 $86,191 $16,070 MH only $100,321 $16,920 $68,346 $15,055 SA only $20,740 $1,880 $17,845 $1,015 Aggregate spending in percent (by column) MH only 83 90 79 94 SA only 17 10 21 6 Spending per capita (dollars) All MHSA $416 $257 $474 $447 MH only $345 $232 $376 $419 SA only $71 $26 $98 $28 Population in millions 290.9 73.0 181.9 36.0 Population in percent 25 63 12 (by row) Aggregate spending in percent (by row) All MHSA 16 71 13 MH only 17 68 15 SA only 9 86 5 As a percent of total healthcare spending (by column) All MHSA 8.1% 9.3% 11.1% 3.1% MH only 6.7% 8.4% 8.8% 2.9% SA only 1.4% 0.9% 2.3% 0.2% Source: SAMHSA Spending Estimates. in general hospitals, with three fourths of this amount spent on care outside of general hospital specialty psychiatric units (i.e., in general medical units) and 10% in specialty psychiatric and substance abuse hospitals. The next largest share of dollars went to MH prescription medications (16%). Thirteen percent of total youth MH dollars was spent on physicians, the majority of which went to psychiatrists. Nine percent of youth MH dollars was spent on other professionals (e.g., nurses, social workers, psychologists). Substance abuse spending The largest percentage (48%) of the $1.88 billion dollars spent on children and adolescents for treatment of substance use conditions was for care provided in specialty substance abuse centers (Table 3 ), which are also the providers receiving the most spending overall. Specialty substance abuse centers focus on providing substance abuse services in outpatient or residential settings. The next largest proportion of youth SA treatment spending went to MSMHOs (15%). Thus, almost two thirds of dollars for treatment of substance use conditions The Journal of Behavioral Health Services & Research 2008 Mental health Table spending by age 2 group by provider, 2003 Provider type All ages Age groups Children and adolescents (less than 18 years) Young and mid-age adults (18 226 64 years) Older adults (65 years and older) Expenditures in billions Total expenditures Total of all service providers and products Total of all service providers General, non-specialty hospitals General hospital, specialty units General hospital, non-specialty care Specialty hospitals All physicians Psychiatrists Non-psychiatrist physicians Other professionals Free-standing nursing homes Free-standing home health Multi-service mental health organizations Specialty substance abuse centers Retail prescription drugs Insurance administration Percent distribution by provider Total expenditures Total of all service providers and products Total of all service providers General, non-specialty hospitals General hospital, specialty units General hospital, non-specialty care Specialty hospitals All physicians Psychiatrists Non-psychiatrist physicians Other professionals Free-standing nursing homes Free-standing home health Multi-service mental health organizations Specialty substance abuse centers Retail prescription drugs Insurance administration $100,321 93,177 69,918 15,927 6,568 9,359 11,673 13,748 9,802 3,946 8,370 6,234 823 13,143 226 23,259 7,145 100 93 70 16 7 9 12 14 10 4 8 6 1 13 226 23 7 $16,920 15,715 13,050 2,626 618 2,008 1,756 2,162 1,484 678 1,478 226 25 5,003 226 2,666 1,205 100 93 77 16 4 12 10 13 9 4 9 226 0 30 226 16 7 $68,346 63,479 44,994 10,910 4,692 6,217 8,796 10,196 7,575 2,620 6,096 976 397 7,624 226 18,484 4,867 100 93 66 16 7 9 13 15 11 4 9 1 1 11 226 27 7 $15,055 13,983 11,874 2,392 1,258 1,134 1,120 1,390 742 648 796 5,258 401 517 226 2,109 1,072 100 93 79 16 8 8 7 9 5 4 5 3 5 3 3 226 14 7 Source: SAMHSA Spending Estimates. Mental Health and Substance Abuse Spending by Age, 2003 MARK et al. Substance abuse Table 3 spending by age group by provider, 2003 Provider type All ages Age groups Children and adolescents (less than 18 years) Young and mid-age adults (18 22664 years) Older adults (65 years and older) Expenditures in billions Total expenditures Total of all service providers and products Total all service providers General, non-specialty hospitals General hospital, specialty units General hospital, non-specialty care Specialty hospitals All physicians Psychiatrists Non-psychiatrist physicians Other professionals Free-standing nursing homes Free-standing home health Multi-service mental health organizations Specialty substance abuse centers Retail prescription drugs Insurance administration Percent distribution by provider Total expenditures Total all service providers and products Total all service providers General, non-specialty hospitals General hospital, specialty units General hospital, non-specialty care Specialty hospitals All physicians Psychiatrists Non-psychiatrist physicians Other professionals Free-standing nursing homes Free-standing home health Multi-service mental health organizations Specialty substance abuse centers Retail prescription drugs Insurance administration 20,740 19,433 19,335 4,359 2,890 1,470 676 1,672 540 1,131 2,636 301 4 1,246 8,441 98 1,307 100 94 93 21 14 7 3 8 3 5 13 1 0 6 41 0 6 1,880 1,762 1,761 183 119 64 74 84 30 55 230 - 0 283 907 0 118 100 94 94 10 6 3 4 4 2 3 12 - 0 15 48 0 6 17,845 16,721 16,622 3,669 2,535 1,134 588 1,514 496 1,018 2,362 90 2 950 7,448 98 1,125 100 94 93 21 14 6 3 8 3 6 13 1 0 5 42 1 6 1,015 951 951 507 235 272 14 74 15 59 44 211 2 14 85 0 64 100 94 94 50 23 27 1 7 1 6 4 21 0 1 8 0 6 Source: SAMHSA Spending Estimates. The Journal of Behavioral Health Services & Research 2008 among youth went to specialty MH and SA organizations. Fourteen percent of youth SA dollars went to hospitals (10% in general hospitals and 4% in specialty hospitals). The proportion of SA treatment spending was greater for other professionals (e.g., nurses, psychologists, social workers) than for physicians (4% to physicians and 12% to other professionals). Young and mid-age adults: spending by provider Mental health spending The largest percentage of the $68.3 billion in spending for young and mid- age adult MH treatment went toward care in hospitals (29%; Table 2 ). General hospitals comprised 16% (7% in MHSA specialty units and 9% outside of MHSA specialty units), while specialty hospitals comprised 13% of total MH spending on adults, a higher proportion compared to other age groups. Another large share of spending (27%) was on prescription medications. This was a much larger percentage of total spending for this age group than for prescription medications for youth or for older adults. As with youth, more was spent on treatment by physicians (15%) than other professionals (9%). About 11% of total dollars was spent on MSMHOs. Substance abuse spending Forty-two percent of the $17.8 billion dollars spent on SA treatment for young and mid-age adults was spent on specialty substance abuse centers (Table 3 ), and only 5% was spent on treatment in MSMHOs. About one 001fth of all young and mid-age adult SA treatment dollars went to general hospitals. In contrast to MH, the majority (14%) was spent in general hospitals with specialty units, and only 6% was spent on medical units that do not specialize in psychiatric or SA treatment. Only 3% or about $600 million was spent in specialty psychiatric or substance abuse hospitals. Twenty-one percent of SA treatment dollars for young and mid-age adults was spent on independent practitioners (8% on physicians and 13% on other professionals such as nurses, psychologists, and social workers). Older adults: spending by provider Mental health spending In stark contrast to younger adults and children, the largest share of MH treatment spending on older adults occurred in nursing homes (35% of the total $15 billion; Table 2 ). Twenty-three percent of older-adult MH spending was on hospitals, with 16% of treatment in general hospitals (8% each in specialty units and outside of specialty units), and 7% in psychiatric specialty hospitals. Less was spent on prescription MH medications by older adults than by children or adults ages 18 to 64. Approximately 14% of older adult total MH spending was for prescription medications. Nine percent of dollars went to physicians and 5% to other professionals. Very little was spent on MSMHOs (about $500 million or 3% of total MH spending on adults age 65 or older). Substance abuse spending Of the $1 billion spent on treatment of older adults for substance use disorders in 2003, half was spent in general hospitals (23% in specialty units and 27% in non- specialty units; Table 3 ). The next largest category was nursing homes, which comprised 21% of the total. Specialty MH and SA centers play a small role on a dollar basis in providing SA treatment to older adults. Only 8% or about $85 million of older adult SA treatment dollars was spent in specialty substance abuse centers, and only 1% was spent in MSMHOs. Older adults also appear to rely less on other professionals for treatment, as compared to youth and mid-age adults. Seven percent of older adult SA treatment spending was on physicians and 4% on other non-physician professionals. The majority of physician spending was for care by those with non-psychiatric specialties ($15 million for psychiatrists versus $59 million on other types of physicians). Mental Health and Substance Abuse Spending by Age, 2003 MARK et al. Spending by age within providers Mental health spending Finally, it is useful to examine the distribution of spending by age within provider and service types (Table 4 ). For MH, the majority of spending for most providers occurred in the largest cohort, the 18 226 64 age group. However, the percentages varied by provider and services. For nursing homes, 84% of MH spending was allocated to older adults. Most spending for prescription MH drugs (79%) was allocated to young and mid-age adults, with only 9% allocated to older adults. For MSMHOs, a disproportionately large share (38%) of spending went to youths. Substance abuse spending Across all providers and services, with the exception of nursing homes and home health, 75% or more of SA treatment spending occurred among the largest cohort 227 adults ages 18 through 64 (Table 5 ). For MSMHOs, 23% of their revenues came from treating youth, 76% from young and middle-aged adults, and 1% from older adults. Implications for Behavioral Health Data on the size and nature of MHSA treatment spending by age have a variety of policy implications, particularly when viewed in the context of other relevant information. One use of these data is to elucidate where most of the spending for care for different age groups is likely to be allocated. The data highlight important issues in each of the age groups. Much of spending for children for MH and SA (30%) is concentrated in MSMHOs and substance abuse centers, highlighting the important role that these organizations play in serving the needs of children. The largest share (48%) of the dollars spent on children and adolescents for treatment of substance use conditions was for care provided in specialty substance abuse centers. This 001nding supports the argument that specialty mental health and substance abuse organizations must develop programs that are uniquely suited to treat children, whose cognitive, developmental, and pharmacological needs require treatment approaches that differ from those of adults. A recent study found that the majority of specialty substance abuse centers that treated large number of adolescents reported having speci 001 c programs for adolescents, although 13% did not, indicating some room for improvement.4 In addition, many substance abuse organizations did not offer all of the specialty pregnancy or HIV services recommended for children and adolescents or co-occurring services, such as comprehensive mental health assessment. For multi-service mental health organizations, the need to focus on youth may be more apparent to providers, as 38% of MH dollars and 23% of SA dollars in MSMHOS go to treating youth. For SA centers, 11% of SA dollars were allocated to youth. However, these percentages may vary widely across providers. Another important issue that this study highlights is the role of prescription drugs in mental health and substance abuse treatment of children. About 1 in 10 MH dollars spent on youth were for prescription drugs (about $2.7 billion in 2003). The growing use of psychoactive drugs among children and the need for more research on their effectiveness and safety in children continues to be apparent. While use of prescription medications among children is clearly an important issue, mid-age adults are by far the largest users of psychoactive medications. Retail prescription drug spending for MH is disproportionately concentrated in the mid-age adult populations. Adults ages 18 through 64 made up 62% of the US population in 2003 but were responsible for 79% of MH prescription drug dollars. In 2003, more than 1 in every $4 spent on mid-age adult MH care was for prescription drugs. Clearly, prescription drugs have become a major method of clinical treatment for mid-aged adults, and the degree to which they are being provided in an adequate manner with the necessary ancillary services is a question for additional research. Although most spending for MH is concentrated in the mid-age adult population, the per capita costs for MH are highest for older adults. This result may, at 001 rst glance, seem coun ter-intuitive: MHSA The Journal of Behavioral Health Services & Research 2008 Table 4 Mental health spending by age group: percent within providers, 2003 Age groups Children and adolescents Young and Older adults (less than mid-age adults (65 years Provider type 18 years) (18 22664 years) and older) Percent distribution by age Total expenditures 17 68 15 Total all service providers and products 17 68 15 Total all service providers 17 68 15 General, non-specialty hospitals 16 68 15 General hospital, specialty units 9 71 19 General hospital, non-specialty care 21 66 12 Specialty hospitals 15 75 10 All physicians 16 74 10 Psychiatrists 15 77 8 Non-psychiatrist physicians 17 66 16 Other professionals 18 73 10 Free-standing nursing homes 226 16 84 Free-standing home health 3 48 49 Multi-service mental health organizations 38 58 4 Specialty substance abuse centers 226 226 226 Retail prescription drugs 11 79 9 Insurance administration 17 68 15 Source: SAMHSA Spending Estimates. prevalence rates tend to fall at older ages. However, it might be explained by the different services used by the older adults. The majority of MH spending on older adults occurs in nursing homes and inpatient settings, which are relatively more expensive on a per episode basis than outpatient and pharmaceutical care. The extensive spending on MH care in these se ttings highlights the need for quality assurance measures for MH care to older adults by these providers. Only 5% of the total SA spending was for treatment of older adults. However, given the aging of the baby boom generation, the spending on SA treatment for older adults may increase.5 Gfroerer and colleagues estimate that the number of older adults that will need treatment for SA will increase from 1.7 million in 2001 to 4.4 million in 2020.6 The aging baby boom population will place increasing demands on the SA treatment system in the next two decades and will require a shift in the focus of treatment and spending. Estimates of MHSA spending by age were calculated previously for 1997.1 Caution must be taken in comparing the 2003 estimates to prior estimates since the methods and underlying baseline data were updated. However, some general observations can be made. The percent distribution of spending by age changed slightly from 1997 to 2003, which is proportionally more dollars going to children and less to adults. In 1997, 13% of MHSA spending went to children, 72% to adults, and 15% to older adults. In 2003, 16% was spent on children, 71% on adults, and 13% on older adults. The percent of total health care spending within each age group going to MHSA remained about Mental Health and Substance Abuse Spending by Age, 2003 MARK et al. Substance abuse spending by Table 5 age group: percent within providers, 2003 Provider type Children and adolescents (less than 18 years) Age groups Young and mid-age adults (18 22664 years) Older adults (65 years and older) Percent distribution by age Total expenditures Total of all service providers and products Total all service providers General, non-specialty hospitals General hospital, specialty units General hospital, non-specialty care Specialty hospitals All physicians Psychiatrists Non-psychiatrist physicians Other professionals Free-standing nursing homes Free-standing home health Multi-service mental health organizations Specialty substance abuse centers Retail prescription drugs Insurance administration 9 9 9 4 4 4 11 5 5 5 9 226 3 23 11 0 9 86 86 86 84 88 77 87 91 92 90 90 30 51 76 88 100 86 5 5 5 12 8 19 2 4 3 5 2 70 46 1 1 0 5 Source: SAMHSA Spending Estimates. constant in the 1997 and 2003 estimates. The most notable difference between the two sets of estimates was the amount of spending allocated to prescription drugs, which more than doubled. In all the age groups, a much larger proportion of spending was for prescription drugs in 2003 as compared to 1997. The SAMHSA spending estimates are an ongoing effort to estimate US spending on MHSA services. Periodic updates to the age estimates 227 that can continue to inform policymakers and others about the unique MH and SA spending issues facing different age groups within the population 227 are planned for future work. Acknowledgment This work was funded by the Substance Abuse and Mental Health Services Administration. The views expressed in the manuscript do not necessarily re 002ect the opinions of the Substance Abuse and Mental Health Services Administration or the Department of Health and Human Services. The Journal of Behavioral Health Services & Research 2008 References 1. Harwood HJ, Mark TL, McKusick DR, et al. National spending on mental health and substance abuse treatment by age of clients, 1997. Journal of Behavioral Health Services Research . 2003;30(4):433226 443. 2. Zuvekas SH. Trends in mental health services use and spending, 1987226 1996. Health Affairs . 2001;20(2):214 226 224. 3. Ringel JS, Sturm R. National estimates of mental health utilization and expenditures for children in 1998. Journal of Behavioral Health Services Research . 2001;28(3):319 226 333. 4. Mark TL, Song X, Vandivort R, et al. Characterizing substance abuse programs that treat adolescents. Substance Abuse Treatment . 2006;31 (1):59 226 65. 5. Patterson TL, Jeste DV.003 The potential impact of the baby-boom generation on substance abuse among elderly persons. Psychiatric Services . 1999;50(9):1184 226 1188. 6. Gfroerer J, Penne M, Pemberton M, Folsom R. Substance abuse treatment need among older adults in 2020: the impact of the aging baby- boom cohort. Drug and Alcohol Dependence . 2003;69(2):127 226 135. Mental Health and Substance Abuse Spending by Age, 2003 MARK et al.