Published online Sept. 23, the commentary, says the field’s main diagnostic tool is the Mental Status Examination. The exam was built around hearing patients.
Clinicians who don’t account for signed languages and hearing differences can potentially mistake communication patterns for symptoms.
If you or a family member has hearing loss, you may need to ask more questions during a mental health evaluation.
The Standard Exam Has Gaps
Hearing loss affects 22.2% of the US population and is also linked to higher risks for depression, anxiety and psychosis.
Deaf and hard-of-hearing patients remain underserved but barriers to care continue to play a role.
Psychiatric settings often treat hearing loss as an accessibility issue but it should also be viewed as a clinical skill.
Jessica Williams MD of Washington University School of Medicine led the authors of the commentary. They say clinicians need to understand how hearing loss and signed languages affect the Mental Status Examination.
Without that knowledge clinicians may misread symptoms. They may also make diagnostic errors.
ASL Can Change a Psychiatric Exam
For Deaf patients who use American Sign Language facial expressions have more than one role. They can communicate emotion and grammar.
A clinician who doesn’t understand ASL may mistake normal language patterns for unusual affect.
The authors also note that physical signing can provide information similar to speech in a traditional exam.
A psychiatrist might look at the amplitude and force of signs rather than the volume and tone of speech. Some signing patterns can signal a problem in the right context.
For example signing in a different direction from the psychiatrist may represent a response to internal stimuli, which can occur with psychosis.
Rigid or repeated signing may point to obsessive-compulsive symptoms. Questions about auditory hallucinations may not make sense for every deaf patient.
A clinician can instead ask whether someone’s trying to signal to them or communicate with them. Language deprivation can make an evaluation even harder.
It can cause dysfluency that looks like disorganized thought or psychosis. An interpreter who isn’t familiar with a patient’s language background may also mistake home signs for neologisms.
The authors recommend talking with the interpreter before and after the session. When dysfluency is significant they recommend using a certified Deaf interpreter along with a hearing ASL interpreter.
Hearing Loss Can Look Like Symptoms
Hard-of-hearing patients face different challenges. Chronic effort to hear can cause listening fatigue.
It may lead to irritability or trouble concentrating and over time, it can also contribute to social withdrawal or depression.
Reduced auditory feedback can change the tone and rhythm of speech. A clinician might mistake this for monotony.
Trying to fill in words or sounds that were missed can also cause confusion. That confusion may look like disorientation, delirium or even paranoia.
There is also something known as the “deaf nod” where patients may pretend to understand because they don’t want to feel embarrassed about asking for clarification.
That can create a hidden communication problem where important clinical details may be missed and treatment instructions may also be misunderstood.
The authors say regular check-ins and teach-back can help. These methods aren’t just polite but they also help clinicians tell the difference between a communication problem and a psychiatric symptom. Clinicians should ask patients what accommodations they need.
Better Access Requires Better Training
The commentary also points to gaps in medical training. Medical students and psychiatry residents get little exposure to mental health care for Deaf and hard-of-hearing patients.
Existing training often focuses on basic communication access instead of clinical issues. Healthcare organizations also need practical accommodations.
These can include sign language interpreters assistive technology such as FM systems and live captioning.
The authors generally favor in-person interpreters over video-remote services. In-person interpreters can build rapport. They may also know regional sign variations and work more directly with the patient.
Questions to Ask Before Treatment
If you or a family member has hearing loss you can ask how a provider handles communication needs before choosing care.
Consider asking:
Does the clinic provide qualified ASL interpreters or live captioning?
Will you have the same interpreter across visits?
Does the clinician use teach-back to check understanding?
Does the provider ask about your communication needs?
It’s also good to pay attention to how clearly the program answers these questions. The answers can tell you whether communication access is part of the treatment itself or something the program handles only when problems arise.
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