4:48 Psychosis raises the question of what constitutes theater. Is this a case study in psychotic depression, a work of art, or both? Can one call language without boundaries a play? What direction remains for contemporary theater to take following total fragmentation?  
 

These concerns have not stood in the way of 4:48 Psychosis being produced - if anything, it seems to be gaining in popularity. What could be stumbling blocks are seen by directors as a challenge to be met creatively. The play’s initial production, at London’s Royal Court (2000) divided the words among three performers. All three initially learned the whole text, and although most lines were eventually allocated, others were voiced spontaneously by different actors from performance to performance. The “action” appeared to take place within the mind of the protagonist. Projections onto a mirror helped create a Rorschach-like effect. As evidence that the play encourages a wide variety of interpretations, in the celebrated TR Warszawa production, six actors embodied discrete characters, creating encounters between a central character and her doctor, family members, or friends. This production, brought to New York in 2014, employed a Polish translation with English surtitles.  Another production, by Theatre du Pif of Hong Kong in 2016, purported to bring “an Asian sensibility” to the play, using a Korean designer and Hong Kong musicians.”  

In conclusion, 4:48 Psychosis is clearly not everyone’s idea of entertainment (one critic likened watching it to being locked in a freezer). However, it provides a beautiful, albeit brutal, window into the depressed, suicidal mind.  

A previous version of this review was published in the NYU Literature, Arts, and Medicine Database.  

Primary Source Sarah Kane: Complete Plays 
Publisher Bloomsbury Methuen Drama 
Place Published New York 
Page Count 43 
Web Art: File:4.48 psychose.JPG – Wikimedia Commons 

Carrie Coon, Letts’ wife, plays Agnes White, a lonely server living in an Oklahoma motel who falls in love with Peter Evans (Namir Smallwood), an AWOL Gulf veteran. Peter becomes increasingly convinced that he is the subject of clandestine experiments, and that he is infested with government-planted bugs. These bugs are, of course, invisible, yet he drags Agnes with him into a seeming folie à deux—a bedlam of flypaper, aluminum foil, and bug zappers.  

Peter’s delusions (and, in turn, Agnes’s) eventually cross a line into a realm in which logic no longer applies. By spilling so far into excess, even occasionally veering into bizarre spoofiness, Bug risks trivializing Peter’s paranoia—a risk especially fraught now that the part is played for the first time by a Black actor.  

Initially, Peter cites a real case of government experimentation: the Tuskegee Syphilis Study, in which poor Black sharecroppers were never told they had syphilis. The experiment ran from 1932 until 1972—long after penicillin became the standard treatment in the mid-1940s. To observe how the disease naturally progressed, researchers deliberately withheld the antibiotic, ending the study only after a press leak. 

This gross violation of ethics is widely believed to have damaged Black Americans’ trust in the medical establishment. But according to medical ethicist Harriet A. Washington [1], “that narrative is flawed and untrue.” While Tuskegee certainly contributes to that distrust, the larger impetus is “four centuries of abuse in the medical arena,” which Washington chronicles in her 2007 book Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present. “In fact, one study indicated that African Americans who had never heard of Tuskegee were more likely to fear vaccine administration and medication design.” 

What if Bug had dialed down Peter’s paranoia and explored it within this broader historical context instead of reinforcing the singularity of Tuskegee? Overemphasizing Tuskegee because of its infamy (or because of one’s ignorance) serves to obscure other historical ethics violations as well as systemic racial inequities that persist today. For instance, what if Peter struggled to access mental healthcare because of structural barriers? 

In her 2021 book Carte Blanche: The Erosion of Medical Consent, Washington mentions an experimental anthrax vaccine that soldiers were required to receive beginning in 1998. “Soldiers of all races were affected,” she writes, “but Blacks were overrepresented because they constituted 12.3 percent of Americans, but were 24.5 percent of the 1.7 million ground troops deployed to the Gulf in 1990 and 26.2 percent of Army reservists in 2001—twice their representation in the population at large, and so at twice the risk of being forced into military research.” 

Many service members reported autoimmune conditions after getting the jab, but the Pentagon attributed their symptoms to “emotional issues,” Washington continues. “The military subsumed vaccine-related illnesses under the nebulous symptomatology of ‘Gulf War Syndrome.’” What if Bug had dramatized that ‘nebulous symptomatology’? 

Peter also references another example of government research: the Edgewood Arsenal experiments. After World War II, the U.S. Army Chemical Corps tested chemical weapons on American soldiers at a secluded research facility on the Chesapeake Bay, exposing volunteers to more than 250 different chemicals, including LSD, mustard gas, and sarin. The studies ended after researchers were accused of ethical transgressions, including issues with informed consent and recruitment. Archival footage, unearthed in a 2022 documentary, shows men “going temporarily blind, reduced to babbling or completely dysfunctional logs, or worse, ready to commit violence upon themselves.” [2] 

Washington argues in Carte Blanche that “the medical crimes that were denounced and punished at Nuremberg have American analogues.” 

“Although not perfect parallels,” she notes, “they share a violent, nonconsensual, and largely racial disparate nature, as well as the frequent invocation of military expedience.” 

In this light, Peter’s condemnation of his doctors as neo-Nazis feels less outlandish than the play permits. Letts may hint that Peter is not entirely psychotic—that his madness holds some truth. But that seed never grows.  

The play ultimately bubbles over (spoiler alert: self-harm, violence, and fire). A future iteration of the three-decades-old play, if there is one, might benefit from taking Peter’s delusions more seriously—and leaving open the possibility that they are, in fact, real. 

Bug will get under your skin, but to what end? 

Bug, through March 8th at the Samuel J. Friedman Theatre in New York; manhattantheatreclub.com/shows/2025-26-season/bug/.  

[1] “Harriet A. Washington on the Narrative Around Vaccine Hesitancy in the African American Community: In Conversation with Andrew Keen.” Keen On from Literary Hub, 19 Mar. 2021, lithub.com/harriet-a-washington-on-the-narrative-around-vaccine-hesitancy-in-the-african-american-community/. 
[2] Simonpillai, Radheyan. “‘It Affected a Great Number of People’: Inside the World of Shocking Military Drug Experiments.” The Guardian, 9 June 2022, theguardian.com/tv-and-radio/2022/jun/09/dr-delirium-and-the-edgewood-experiments-documentary. 

Web image by Matthew Murphy.

Through playful videos hashtagged #LiveLaughLexapro and #LexaproGirly, Tiktok and Instagram creators have transformed the selective serotonin reuptake inhibitor into a selective, if relatable, lifestyle for the enlightened and empowered—stigma be damned. Our society is preoccupied with chemical selfhood[1], with mental illness arguably normalized to the point of sun-kissed romanticization. 

Psychopharmaceuticals receive a different treatment in the snow-blanketed mansion of The Housemaid, based on Freida McFadden’s same-named novel and directed by Paul Feig. (Spoilers ahead for the campy thriller!) 

Millie Calloway (a mostly lackluster Sydney Sweeney), who is on parole, becomes the titular live-in maid for a wealthy family. She finds Haldol, an antipsychotic, in the medicine cabinet of her erratic boss, Nina Winchester (a delightfully unhinged Amanda Seyfried). This discovery leads Millie to believe that Nina is mentally ill, confirming the story that the latter’s husband Andrew (an initially charming Brandon Sklenar) and gossipy so-called friends have been building: that Nina is deceitful and dangerous. 

In reality, Nina’s outbursts and mood swings are in part a reaction to Andrew’s abuse. But she also uses the perception that she is unstable to her advantage, exaggerating her behavior in an attempt to engineer her escape. 

By locking both of its female leads, at one point or another, in an attic room, The Housemaid alludes to the “madwoman in the attic” trope, theorized in 1979 feminist literary criticism by Sandra Gilbert and Susan Gubar. In their seminal work, they explore how 19th-century women writers used their texts to resist the patriarchy.  

The quintessential example is Bertha Mason, the first wife of the eventual husband of the eponymous narrator of Charlotte Brontë’s Jane Eyre. Another example: the postpartum protagonist of Charlotte Perkins Gilman’s “The Yellow Wallpaper,” whose physician husband prescribes her a rest cure and confines her to an upstairs nursery. Her resulting insanity is an embodiment of, and protest against, the subjugation of women. As literary critic Elaine Showalter[2] writes, the madwoman “refuses to speak the language of patriarchal order.”  

Albeit to a lesser extent than Nina, Millie is also cast as a madwoman. Toward the beginning of the film, she seems anxious and hyper-vigilant, and her specific crime is kept secret, leaving her reliability ambiguous. And, at first, Nina’s freedom—her rebellion against the patriarchy—comes at the expense of Millie’s, hardly an example of women supporting women. 

But Nina’s 7-year-old daughter Cece (Indiana Elle) encourages her mother to rescue Millie, who ultimately defeats Andrew. The police officer (Alexandra Seal) notices inconsistencies in Nina’s account but, owing to a plot contrivance, investigates no further. The Housemaid ends with Millie accepting a new job, once more as a knife-savvy housemaid for an abused woman. 

Rebecca Sonnenshine’s twist-filled screenplay is highly entertaining, but it is no masterpiece. That said, we can examine The Housemaid through the lens of mad studies, a field of scholarship that places mental distress within broader social and political contexts. This approach extends the notion, often attributed to psychiatrist R.D. Laing, that insanity is a “perfectly rational adjustment to an insane world.” Bradley Lewis[3], another psychiatrist, maintains that “psychic difference from the norm” can, in some cases, be something “to celebrate.”  

Mille’s vengeance-driven crimes are ethically understandable; however, they are legally questionable, and most mad-studies scholars would likely not exalt them. But instead of pathologizing her and Nina’s actions, we can read them as efforts to combat Andrew’s patriarchal control. 

Additionally, as Lewis underscores, healthcare professionals must seek to understand how social and political forces shape the lives of their patients and center their perspectives and narratives. Had Nina’s clinicians taken her seriously, she, Cece, Millie, and even Andrew would have been spared much pain. 

Millie finds an unflushed pill in a toilet, suggesting that Nina doesn’t take her Haldol. Unlike #LexaproGang members, she has been prescribed medication against her will. Admittedly, medication can play an important role in managing mental illness, but The Housemaid emphasizes that it cannot substitute for structural change. Even if mental illness has in part been commodified by social media, the film reminds us that what is labeled madness may, in fact, be an attunement to a world that too often denies women credibility and agency—a problem that demands not merely treatment, but transformation. 

The Housemaid. Directed by Paul Feig, performances by Sydney Sweeney, Amanda Seyfried, Brandon Sklenar, and Indiana Elle, Lionsgate, 2025. 

[1]Metzl, Jonathan M. The Protest Psychosis: How Schizophrenia Became a Black Disease, Beacon Press, 2010. 
[2]Showalter, Elaine. “Representing Ophelia: Women, Madness, and the Responsibilities of Feminist Criticism.” Shakespeare and the Question of Theory, edited by Geoffrey H. Hartman and Patricia Parker, Routledge, 1985, pp. 77-94. 
[3]Lewis, Bradley. “Rethinking Psychiatry with Mad Studies.” Mad Studies Reader: Interdisciplinary Innovations in Mental Health, edited by Bradley Lewis, Alisha Ali, and Jazmine Russell, Routledge, 2024, pp. 435-455. 

Web image by Medhum.org

A precocious young person on a track to success, Wang experiences a manic episode at Yale that leads to her first hospitalization. After a second hospitalization, her college washes its hands of her. Hitting roadblocks time and time again requires her to rebuild her life over and over. This is not a conventional chronological autobiography but rather essays that provide different approaches to the author’s experience of mental illness. The plural “schizophrenias” of the title encompasses the whole schizophrenic spectrum of disorders. As Wang explains, her own diagnosis is “the fucked-up offspring of manic depression and schizophrenia” (p. 10).   

In an essay entitled “High-Functioning” we learn how the author, having been a fashion editor, knows how to pass for normal: “My makeup routine is minimal and consistent. I can dress and daub when psychotic and when not psychotic. I do it with zeal when manic. If I’m depressed, I skip everything but the lipstick. If I skip the lipstick, that means I haven’t even made it to the bathroom mirror” (p.44).   

Later, in “The Choice of Children,” volunteering at a camp for bipolar children makes Wang think about what it would be like to inflict her diagnosis on her own offspring. In “Reality, On-Screen” she attempts to convey the sensation of decompensating to psychosis. And in “Yale Will Not Save You” she considers the failure of universities to accommodate mentally ill students.  

This is a special and rare book. As with Elyn R. Saks in The Center Cannot Hold, Wang’s disability seems not to have robbed her of her cognitive faculties, resulting in a sense of lucidity. Yet, at the same time, we are never far from madness. As a result, the essays glisten like polished jewels while the author’s voice retains the air of authenticity.   

While Wang has understandably had ambivalent experiences, in every case where The Collected Schizophrenias might have lapsed into an anti-psychiatry rant, the author instead considers a range of perspectives. She is devoted to taking her medication, yet she open-mindedly explores alternative therapies, spirituality, and even the notion that her illness might have bestowed talents or some evolutionary advantage on her.   

We should not have to be reminded that once civilians become patients they do not lose their intelligence. Wang writes that “a primary feature of the experience of staying in a psychiatric hospital is that you will not be believed about anything” (p. 98). Indeed, when she is asked how she is doing and she replies she is doing well, she is said to be lacking in insight. At other times, she is advised by certain well-meaning people that given her diagnosis “I should be proud of how coherent I am” (p. 54), and by others “who don’t believe in mental illness… that in other cultures, a person who would be diagnosed with schizophrenia in the West might be lauded as a shaman and a healer…They are likely to be the type who boast about never taking aspirin for a headache” (p. 23).  

There are many insights to be found in this book that should prove eye-opening to mental health practitioners. It should be required reading for anyone who wants to understand the experience of having an illness.   

Publisher Graywolf Press 
Place Published Minneapolis 
Edition 2019 
Page Count 202 

Web image from Wikicommons
An earlier version of this review was published in the NYU Literature, Arts, and Medicine Database. 

Author George Scialabba ascribes his “exceptionally flimsy…shock absorbers” to his “constantly worried” parents (p.3). While studying at Harvard he becomes involved with a strict religious organization. After leaving that group he undergoes a crisis of faith and his first episode of depression. Paralyzed by self-doubt, he drops out of graduate school and begins a cycle of clerical jobs that are beneath his intellectual capability. After many years he gradually wins distinction as a freelance essayist. However, due to his incapacitating symptoms he never has a steady writing job and has difficulty attaining financial security.   

In his introduction, Scialabba tells us that “the pain of a severe clinical depression is the worst thing in the world. To escape it, I would do anything” (p.1). As attested to by the notes of his well-meaning psychiatrists and psychotherapists, he has diligently applied himself to a wide variety of treatments. Sadly, if anything he gets worse over time, and eventually requires electroconvulsive therapy.  

The task of wading through more than a hundred pages of treatment notes induces a feeling of helplessness. This gives us a taste of the author’s own experience of his illness. He often seems to get better or worse without rhyme or reason. Diagnoses come and go. At various times he has been called borderline, obsessive-compulsive, narcissistic or schizoid. He himself questions the literary quality of the notes, considering them “anti-writing” (p.7). Nevertheless, persevering through the material does yield insights for the reader.   

For one thing, the notes document changes in psychiatry over the past half century. The early note takers took their time, and their writing is thoughtful and descriptive. Later notes are comparatively terse and center on the patient’s response to medication. The author suggests that the change reflects a greater fear of litigation. The reality is multifactorial. Less attention is devoted nowadays to understanding a patient’s psychodynamics. Insurance companies pay for symptom relief and want documented results.  

Any sense of tedium the reader might feel from reading the author’s mental health records is made up for by his “tips.” Scialabba gives practical suggestions about pharmaceuticals, what to eat, and how to sleep. Sufferers of depression will be pleased to hear about these things not from a doctor, but from someone who has been through the same ordeal.  

In short, How To Be Depressed is a self-help book that is somewhat out of the ordinary, and whose flippant title belies its serious content. It provides an intellectual perspective on a devastating and common disease. 

Publisher University of Pennsylvania Press 
Place Published Philadelphia 
Edition 2020 
Page Count 146 

Web image created by Medhum.org
An earlier version of this review was published in the NYU Literature, Arts and Medicine Database. 

A MacArthur Fellow and author of several acclaimed novels, Antrim has previously published a memoir of his upbringing with his alcoholic mother. In this new memoir, flashbacks of childhood neglect and chaos are juxtaposed with the present day as he takes the reader through the acute phase of his illness: a lengthy hospitalization, a course of ECT, discharge from the hospital, rehospitalization, and eventual stabilization.  

The author considers his condition to be suicide, noting that “depression is a concavity, a sloping downward and a return. Suicide, in my experience, is not that. I believe that suicide is a natural history, a disease process, not an act or a choice, a decision or a wish…I will refer to suicide, not depression” (pp. 14-15).   

The book ends on a hopeful note. After several relationships that might be described as codependent, Antrim meets his current partner, whom he marries. He sees the roof of his building through his window and remembers a certain Friday in April but is comforted by the sound of his wife playing Chopin and Bach on the piano.  

This is an exceptionally brave book. Antrim does not attempt to whitewash his situation in any way. Surely it is humiliating for someone so successful to acknowledge he has been utterly debilitated. He loses track of time. He gains weight and cannot fit into his clothes. His new book is released, but he is in no condition to help promote it. At first, he objects to being called psychotic but eventually it comes as a relief to know he is understood. One Friday in April will be inspirational to others who have suffered to see how an accomplished person is reduced to being allowed to use his razor only under strict supervision.   

At times Antrim touches on the link between mental illness and creativity. If he had hoped the cathartic exercise of writing about his childhood would have stopped his illness he learns otherwise: “Writing had not stopped my dying. (p. 80)” At another point, his friends joke that his diagnosis “might enhance my literary reputation” (p. 115). Finally, in one of the more poignant episodes in the book, Antrim gets a call from the novelist David Foster Wallace and is encouraged to undergo ECT. He has an excellent response to that treatment, but later learns that Wallace has hanged himself.  

While a diagnosis of psychotic depression fits best with the range of symptoms the author manifests, his point about suicide as a distinct disorder is well taken. In fact, the most recent edition of the DSM (Diagnostic and Statistical Manual) took the major step of including Suicidal Behavior Disorder as a “condition for further study.” This corroborates the author’s experience and means that SBD might be included in a later edition. (see also https://www.frontiersin.org/articles/10.3389/fpsyt.2020.499980/full)   

Those who are looking for an exposé or critique of the mental health system will not find it here. Antrim credits his psychiatrists and the hospital with helping him get through an unbearable time. One Friday in April is a book that will give reassurance to people who have endured suicidal thoughts that if they persist they will get better.  

Publisher W.W. Norton & Company 
Place Published New York 
Edition 2021 
Page Count 141 

Web image from Wikicommons
An earlier version of this review was published in the NYU Literature, Arts and Medicine Database 

The narrator in this three-stanza poem observes men in a mental hospital who suffer from what at the time (World War I) was called shell shock and now might be labeled post-traumatic stress disorder. In any case, they are insane; they relive the “batter of guns and shatter of flying muscles.”

For these tortured souls, “sunlight seems a bloodsmear” and “dawn breaks open like a wound that bleeds afresh.” They cannot escape their hideous memories of the warfare. The narrator sees them as living in hell, and he accepts for all society the blame for what has happened to them–we, he says, have “dealt them war and madness.”

Wilfred Owen is recognized as the master poet of the First World War. Writing from firsthand experiences, both in combat and in a hospital recovering from battle fatigue, Owen gave us image after image of how horrible this war was — how the idealized notions of heroism and manly valor meant next to nothing when one was trying to survive gas attacks and bombs dropped from planes. Owen was killed a week before the armistice.

In this poem he opens with a series of questions about who these mental cases are, why they rock back and forth in some kind of purgatory, why they are so tortured with panic and misery. In the second stanza, he answers the opening questions: these are the men whose minds have been ruined by their war experiences, for whom the grotesque carnage of the war was “rucked too thick for these men’s extrication.”

In the final stanza, he explains why these men are so tortured by their memories. And, typical of Owen, he points out that everyone who supported the war contributed to the madness of these mental cases.

📖 Read the poem

The Poems of Wilfred Owen
Wilfred Owen
Publisher: W. W. Norton
Edition: 1986
Editors: Jon Stallworthy
Place Published: New York

A previous version of this review was published in the NYU Literature, Arts, and Medicine Database (Litmed).
Web image created by Medhum.org

View poem from Poetry Foundation

This beautiful poem in The Collected Poems of Theodore Roethke appears in a section called “Sequence, Sometimes Metaphysical.” It is a penetrating rendering, at one and the same time, of “pure despair” and of transcendence; of the curse and simultaneous exaltation of heightened awareness; of the personal experience of “madness,” “my shadow pinned against a sweating wall,” “the edge is what I have,” and of a more profound soul-searching that contemplates union with nature and with God: “I climb out of my fear / The mind enters itself, and God the mind, / And one is One, free in the tearing wind.”

Roethke, a Pulitzer Prize winning poet, suffered from manic depressive illness. This poem is remarkable in conveying a life experienced between extremes and at the edge; we might even recognize elements here that surface from time to time in ourselves. But the poet probes beyond mere personal anguish and that is, perhaps, how he survives.

A Film about Theodore Roethke from PublicResource.Org

Remarkable People – Theodore Roethke by Seattle Colleges Cable Television

The Collected Poems of Theodore Roethke
New York: Doubleday, 1966, 270 pages

An earlier version of this review was published in the NYU Literature, Arts, and Medicine Database (Litmed).
Web image by Anchor Lee 

At one point Ragin accidentally visits Ward #6, the mental ward, where he encounters Ivan Gromov, a brilliant patient, and strikes up a conversation with him.  Gromov, who carries a diagnosis of paranoia, loves life passionately.  His passion attracts Ragin, whose sensibilities are blunted by the emotional numbness from which many physicians suffer.  Ragin is attracted to Gromov like a moth to a candle. He begins to visit Ward 6 daily to debate with Gromov. Since the other doctors never visit Ward 6, this behavior is considered very peculiar. 

Ragin yearns to feel something, anything, even to experience suffering, rather than to remain suspended in his emotionless cocoon.  He develops an obsession that only suffering can redeem him.  This obsession makes him even more dysfunctional, a situation which allows a junior doctor to have him fired as hospital director and, ultimately, admitted to Ward #6 as mentally ill.  Once Ragin has become a patient, a “nobody,” the ward orderly hits him, thereby giving him the opportunity to suffer.  Shortly thereafter, he has a stroke and dies.

Enormous demands and poor working conditions contribute to Ragin’s predicament, but Chekhov suggests that Ragin’s character is also deficient.  Something is missing.  He experiences a sense of futility and numbness.  Is this an inevitable consequence of medical practice?  Or is he particularly vulnerable to burnout?  The deeper theme in “Ward No. 6” is Ragin’s failure to live an authentic life, to discover a sense of wholeness and meaning in his existence.  It is possible that Ragin’s early enthusiasm for hospital practice disguised the fact that he never came to terms with his own needs and values.  

Lady With Lapdog and Other Stories
Anton Chekhov
David Magarshack (Ed.)
London, Penguin Books, 1964.

A previous version of this review was published in the NYU Literature, Arts, and Medicine Database (Litmed).

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