Jessica Williams, MD1,2; Laura Shapiro, MSW, LCSW2; Kristina H. Petersen, PhD3,4
Hearing loss affects 22.2% of the US population, or more than 70 million people nationwide,1 and is associated with increased risks for many mental health conditions, including depression, anxiety, and psychosis,2 which confer notable disability burdens themselves. As such, Deaf and hard-of-hearing (DHoH) patients face elevated psychiatric morbidity yet remain underserved because of persistent barriers in care. Within psychiatric settings, hearing loss is often framed as an accessibility concern, rather than a domain of clinical competency, reflecting in part limited professional training in DHoH mental health.3 However, psychiatrists must understand how hearing loss and signed languages fundamentally influence the Mental Status Examination (MSE), the field’s primary diagnostic tool. Failure to account for these factors can lead to misattributed symptoms, diagnostic errors, and patient mistrust and disengagement.3,4
The DHoH population is highly heterogeneous; for the purposes of this Viewpoint, we will consider 2 groups: Deaf sign language users, and HoH individuals who primarily use speech and device-mediated/residual hearing. Deaf subcultures do not identify as disabled, but as a linguistic minority that uses signed language. HoH individuals range in their communication preferences and navigate the world with varied access to sound and speech. Both groups experience what is colloquially known as the “deaf tax,” referring to the emotional, cognitive, and financial burdens that stem from systemic barriers and limited awareness among the hearing public.5 Furthermore, DHoH patients may have low mental health literacy, a byproduct of lifelong communication barriers that limit incidental learning and access to health information.2 As such, they may require additional psychoeducation to understand the goals of the encounter, their diagnosis, and the importance of treatment adherence. Ultimately, both Deaf and HoH groups face many obstacles in mental health care that require distinct clinical adaptations.
Deaf patients who use American Sign Language (ASL) require skilled interpreters to facilitate the encounter, as well as careful interpretation of the MSE by the psychiatrist. Consider how ASL is structured differently from spoken English: for example, “this week has been very stressful,” can be signed in ASL as [PAST-WEEK ME STRESSED] with puffed cheeks to exhibit high levels of stress. Facial expressions can therefore reflect both emotional affect and linguistic fluency. Additionally, physical sign characteristics provide clinical data analogous to that captured in the traditional “Speech” section of the MSE.4 For example, instead of volume or tone, a psychiatrist would note the amplitude and forcefulness of a patient’s signs. Certain sign language patterns may also signify psychopathology: signing in a different direction from the psychiatrist may represent a response to internal stimuli, as in psychosis,4 while rigid, ritualistic repetitions of a specific sign may reflect obsessive-compulsive pathology. And in Deaf patients, auditory hallucinations may not be pertinent3; instead, the psychiatrist might ask, “Is someone trying to signal to or communicate with you?” Because mental health–specific training for ASL interpreters is rarely offered,6 it is incumbent on the psychiatrist to develop these clinical competencies and partner strategically with the interpreter to maintain diagnostic accuracy.3,6 Consistent use of the same interpreter across encounters is also recommended7 for identifying subtle differences in mental status over time.
Language deprivation, which is common among Deaf signing populations, can cause significant dysfluency that mimics disorganized thought or psychosis. Hallmarks of language deprivation include incorrect sign usage, difficulties with abstract reasoning, and syntactical errors.4 Similarly, idiosyncratic “home signs” that developed because of language deprivation may be mistaken as neologisms by an unaware interpreter. An interpreter unaware that the psychiatrist is monitoring for signs of psychopathology may “clean up” dysfluent or disorganized language into coherent English, inadvertently masking underlying thought disorders. These considerations can be supported by prebriefing and debriefing with the interpreter regarding the patient’s language fluency and the psychiatrist’s goals for the encounter. In cases of significant dysfluency, a certified Deaf interpreter should work alongside the hearing ASL interpreter to support mutual comprehension.4
For HoH individuals, hearing loss often necessitates reliance on context clues and speech-reading to fill in missed information. Auditory cues are further disrupted by confounders such as background noise, masks, poor enunciation, strong accents, or rapid speech. This chronic auditory strain can cause listening fatigue, potentially manifesting as irritability or diminished concentration, or can longitudinally predispose someone to social withdrawal or depression.5 Reduced auditory feedback can also alter a HoH patient’s tone and prosody, mimicking monotony or altered speech rhythm. Furthermore, incorrectly attempting to fill in missed auditory information can lead to confusion5 that resembles disorientation, delirium, or even paranoia.
Another common challenge is social bluffing (also known as the “deaf nod”), where patients across the DHoH spectrum feign comprehension to avoid the perceived embarrassment of asking for clarification.2 This hidden breakdown in communication, often exacerbated by limited mental health literacy, can result in missed clinical details and misunderstood treatment instructions. As such, regular check-ins and teach-back methods are not only ethically but also diagnostically essential. Psychiatrists must explicitly ask what accommodations are needed, establish an environment in which HoH patients feel comfortable requesting clarification as needed, and keep in mind that accommodation needs can change over time.
With 1 in 5 individuals in the US population experiencing hearing loss,1 every psychiatrist will inevitably encounter many DHoH patients throughout their career. However, medical students and psychiatry resident trainees receive minimal exposure to disability or DHoH mental health considerations. When such education is offered by a training program, it is minimal and often focused on basic communication access rather than clinical relevance and cultural humility.3,8 Essential topics that should be covered include the deaf tax and the social model of disability,5 hearing loss-relevant adaptations to the MSE,3 and interpreter collaboration (a practice that is also relevant for non–English-speaking patients6). It is also best practice to consult DHoH community members when designing and delivering such educational material.4
Beyond clinician training, mental health organizations must ensure that clinical settings are equipped with necessary communication accommodations, including sign language interpretation and assistive technologies such as frequency modulated (FM) systems or live captioning.9,10 In-person ASL interpreters, often hired through agencies, are typically preferred to video-remote interpreters,7 as they better facilitate clinical rapport, are more likely to be aware of regional sign variants, and can work directly with the patient to understand what is being signed. Local deaf schools or community-based organizations may have recommendations for quality interpretation agencies, and the patient themselves might have preferences for a specific interpreter or agency. Ultimately, moving beyond legal accommodation compliance toward embracing clinical competence is essential to provide equitable psychiatric care for DHoH patients.
In sum, without competency in DHoH mental health care, psychiatrists risk misunderstanding both what patients say and how they think. Factors such as language deprivation and social bluffing confound the MSE, thus driving potential misdiagnosis and inappropriate treatment. Careful diagnostic consideration and cultural humility are therefore paramount to providing effective, quality psychiatric care for DHoH patients. Developing competency in DHoH psychiatric care can strengthen not only disability-informed practice but also psychiatrists’ ability to care for all linguistically and culturally diverse patients.
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