Speech is the bridge between observable behavior and the thoughts you can't directly see. The way a patient speaks tells you something about their mental state independent of what they're saying. Document speech systematically; it is not the same as thought process.
Dimensions of speech: rate (fast? slow? normal?), rhythm (smooth? halting? fragmented?), volume (loud? soft? whispered?), articulation (clear? slurred? dysarthric?), latency (the delay before responding — short or prolonged?), prosody (varied with emotional inflection or monotone?), amount (talkative or sparse?).
Patterns suggest differentials. Pressured speech — rapid, hard to interrupt, often loud — points toward mania, anxiety, or stimulant intoxication. Slow, sparse speech with prolonged latency suggests depression, sedation, or parkinsonism. Slurred speech with altered mental status suggests intoxication, neurologic emergency (stroke, intracranial process), or severe medication toxicity. Mutism suggests catatonia, severe depression, dissociation, selective mutism, or aphasia. Monotone speech with reduced prosody suggests negative symptoms of schizophrenia, Parkinson's disease, depression, or hypothyroidism.
Speech versus thought process is the most important distinction. Speech is the delivery — how words come out. Thought process is the structure — how ideas connect. A patient can have linear thought process but slow speech (severe depression, parkinsonism). A patient can have rapid speech but disorganized thought process (florid psychosis). Document them separately. They produce different differentials and different treatments.
Cultural and native patterns matter for interpretation. Some languages and some regional speech patterns sound to outside ears like pressured speech but are normative within the patient's community. Accents are not pathology. Calibrate against the patient's baseline if known.
Sudden change is a warning sign. The patient whose speech is suddenly different from baseline — new slurring, new disorganization, new latency — warrants medical evaluation. Stroke, intoxication, medication toxicity, severe metabolic disturbance can present this way.