To put it simply, I absolutely adored this book. I will never, ever forget the bizarre surreal experience of exploring the asylum and having no idea what was going on, the desperate struggle for survival, the dreamy, jaundiced quality to everything... just absolutely 10/10 on atmosphere.

I was a player, so can't comment on anything behind the scenes.

I want to give huge kudos to Paizo for setting a book in an asylum and not making mental illness the real terror, or making the place terrifying because of its mentally ill inmates. The place was beset by real monsters, which made the challenges faced by the staff who were trying to protect the patients all the more upsetting. The patients were handled sensitively and some were truly tragic, and none were monsters simply because of their afflictions. In a setting often beset by lazy, ignorant writing this was a real triumph.

It's not easy to tackle cosmic horror in a game where the players are accustomed to being empowered and are assumed to be able to kill everything they face. I think this book handled it admirably. The encounters seemed a little harder than I'm used to in a first book (perhaps subjective) and the things themselves were horrifying enough that even defeating them wouldn't exclude us from the psychological trauma of facing them down. It rewards thoughtful roleplay with a thought to real psychological consequences.

After reading other reviews of this entire AP, I realize that it holds much greater delights for those who are extremely familiar with the source material and perhaps comes across as bizarre or underwhelming for those who don't know it, or who have a very limited or stereotyped idea of what weird fiction and cosmic horror should be. That's a shame, but I want to add my voice to say that I think this AP was (largely) a unique and wonderful experience, and an excellent way to bring cosmic horror themes to a combat-oriented role playing game.

One minor point of note - I don't think we'd have made it through this AP if we'd used the sanity system out of the box. Too many things would be utterly ruinous to the point where we'd have been gibbering idiots before even the halfway point. We just ran a houseruled version which worked neatly enough, though I'd be interested to hear how it went for anyone who just went for it as is!