The Barriers to Mental Health Services Scale Revised: Reliability, Validity, and Underlying Structure

Introduction: It is understood that older adults underutilize mental health services; however, it is unclear which factors create the biggest barriers. The purpose of this study was to revise the Barriers to Mental Health Services Scale (BMHSS), previously developed and validated by these authors (Pepin, Segal, & Coolidge, 2009). We developed this scale to address a gap in the literature; although barriers had been measured separately no comprehensive measure had been developed. The BMHSS addressed this by concurrently measuring a number of barriers making it possible to examine them in relationship to each other. The BMHSS is a self-report scale comprised of 10 possible barriers to mental health service use, including transportation, finding a psychotherapist, physician referral, psychotherapists’ qualifications, ageism, help seeking, stigma, and insurance/ payment concerns. The BMHSS’s primary strength is providing a comprehensive tool measuring a number of barriers potentially instrumental in preventing geriatric mental health service use. However, the instrument has several limitations. Weaknesses include: a) an inconsistent distribution of items across subscales, with some subscales comprised of 12 items and others only containing 3; b) Cronbach’s alpha values below the acceptable level (.7) for 4 subscales (finding a psychotherapist [.32], belief that depressive symptoms are normal [.48], physician referral [.61], and ageism [.63]); c) a lack of convergent validity analyses; and d) the absence of analyses examining the underlying scale structure. Methods: In the present study, we revised the BMHSS, resulting in the Barriers to Mental Health Services Scale Revised (BMHSS-R). The BMHSS-R is an improved, shorter, and more user-friendly instrument, which was achieved by changing the response format, adding new items, eliminating some existing items, and balancing the number of items on each subscale in the original measure. Younger (n 1⁄4 499, M 1⁄4 22.03 years) and community-dwelling older (n 1⁄4 100, M 1⁄4 72.09 years) adults completed the BMHSS-R. Results: Internal consistency ranged between .55 and .85, with 7 of the 10 subscales’ alphas being over .70. The subscales of stigma and help seeking were moderately correlated with existing measures. The stigma subscale was significantly and positively correlated with The Beliefs Toward Mental Illness Scale (Hirai & Clum, 2000), r(589) 1⁄4 .42 p < .001. The help seeking subscale was significantly and negatively correlated with the Willingness to Seek Help Questionnaire (Cohen, 1999), r(588) 1⁄4 -.44, p < .001. We used principal component analysis to explore the underlying structure of the measure. Ten components with eigenvalues above 1 comprise the underlying structure. These explained the following percent of variance, respectively: 29.14%, 6.60%, 5.25%, 4.13%, 3.37%, 3.09%, 2.77%, 2.55%, 2.43%, and 2.40%. Items for the subscales were all supported through PCA. However, some subscales (i.e., confidence in psychotherapists’ qualifications and ageism; stigma and knowledge and fear of therapy) were not well represented as independent components, instead having one underlying component whereas another subscale (i.e., transportation) was split into two components. Conclusions: Revisions to the BMHSS resulted in improved reliability and validity. This study provides a needed contribution to the field by expanding and improving tools available to assess barriers to mental health services for older adults. Valid measurement of barriers may be helpful in identifying improvements that could lead to improved design and delivery of services, facilitating more appropriate use of services. Also, such a scale could be used in intervention studies to illuminate previously unmeasured variables responsible for participant differences in engagement and intervention use patterns.