Hearing Impairment in Schizophrenia: The Elephant in the Room

Hearing is fundamental to communication and may be particularly relevant in schizophrenia, yet hearing function remains insufficiently considered in psychiatric research and clinical practice. Population-based evidence links hearing loss to psychotic experiences, while emerging clinical evidence suggests that hearing loss may also be more prevalent in individuals with schizophrenia, while behavioral and neurophysiological studies further demonstrate abnormalities across several levels of auditory processing. Hearing difficulties may also complicate psychiatric and cognitive assessment: unrecognized hearing loss can affect performance on some verbally administered cognitive tasks, whereas auditory processing deficits may occur despite normal pure-tone hearing sensitivity. Importantly, these findings should not be interpreted as indicating that hearing abnormalities explain the broader cognitive phenotype of schizophrenia, since auditory task performance may itself be influenced by cognitive, attentional, language, pharmacological, and clinical factors. We argue that hearing deserves greater attention as a clinically relevant and, in some cases, modifiable aspect of communication and assessment in schizophrenia, while its potential impact on broader clinical and functional outcomes requires further investigation. A stepwise approach incorporating hearing sensitivity, speech perception, and, when indicated, comprehensive auditory processing evaluation may facilitate more accurate assessment and closer collaboration between psychiatry and audiology.