Insanity

Insanity plays a strong part in the elements of horror, as fear is a cloying presence that can unhinge the mind. The madness that takes hold can be a signpost of horror, as the protagonists meet twisted minds that have been broken by inhuman creatures, as well as mortal born cruelties like war and terror.

Here we give codified rules on how sanity (and the lack thereof ) can play a role in your game, and how you can inject the substance of sanity into your game, creating a mood of fear and uncertainty.

• Different madness rules (use HP as madness, and dying gains you a permanent insanity)
• Psychic damage types now deal Sanity damage.
• Permanent Insanity can only be removed through extensive downtime activities or divine intervention Insanity can serve as a mechanical disadvantage against certain creatures.

As a GM, you can elect to let a player survive “death”, but gain an insanity specific to the cause of death.

Insanity can be a source of inspiration, may work well with backgrounds for RP purposes.

Madness

In a typical campaign, characters aren’t driven mad by the horrors they face and the carnage they inflict day after day, but sometimes the stress of being an adventurer can be too much to bear. If your campaign has a strong horror theme, you might want to use madness as a way to reinforce that theme, emphasizing the extraordinarily horrific nature of the threats the adventurers face.

Going Mad

Various magical effects can inflict madness on an otherwise stable mind. Certain spells, such as contact other plane and symbol, can cause insanity, and you can use the madness rules here instead of the spell effects in the SRD. Diseases, poisons, and planar effects such as psychic wind or the howling winds of Pandemonium can all inflict madness.

Some artifacts can also break the psyche of a character who uses or becomes attuned to them.

Resisting a madness-inducing effect usually requires a Wisdom or Charisma saving throw.

Madness Effects

Madness can be short-term, long-term, or indefinite.

Most relatively mundane effects impose short-term madness, which lasts for just a few minutes. More horrific effects or cumulative effects can result in long-term or indefinite madness.

A character afflicted with short-term madness is subjected to an effect from the Short-Term Madness table for ldl0 minutes.

A character afflicted with long-term madness is subjected to an effect from the Long-Term Madness table for ldl0 x 10 hours.

A character afflicted with indefinite madness gains a new character flaw from the Indefinite Madness table that lasts until cured.

Short-Term Madness

d%	Effect (lasts ldl0 minutes)
01-20	The character retreats into his or her mind and becomes paralyzed. The effect ends if the character takes any damage.
21-30	The character becomes incapacitated and spends the duration screaming, laughing, or weeping.
31-40	The character becomes frightened and must use his or her action and movement each round to flee from the source of the fear.
41-50	The character begins babbling and is incapable of normal speech or spellcasting.
51-60	The character must use his or her action each round to attack the nearest creature.
61-70	The character experiences vivid hallucinations and has disadvantage on ability checks.
71-75	The character does whatever anyone tells him or her to do that isn’t obviously self-destructive.
76-80	The character experiences an overpowering urge to eat something strange such as dirt, slime, or offal.
81-90	The character is stunned.
91-100	The character falls unconscious.

Long-Term Madness

d%	Effect (lasts ldl0 x 10 hours)
01-10	The character feels compelled to repeat a specific activity over and over, such as washing hands, touching things, praying, or counting coins.
11-20	The character experiences vivid hallucinations and has disadvantage on ability checks.
21-30	The character suffers extreme paranoia. The character has disadvantage on Wisdom and Charisma checks.
31-40	The character regards something (usually the source of madness) with intense revulsion as if affected by the antipathy effect of the antipathy/sympathy spell.
41-45	The character experiences a powerful delusion. Choose a potion. The character imagines that he or she is under its effects.
46-55	The character becomes attached to a “lucky charm,” such as a person or an object, and has disadvantage on attack rolls, ability checks, and saving throws while more than 30 feet from it.
56-65	The character is blinded (25%) or deafened (75%).
66-75	The character experiences uncontrollable tremors or tics, which impose disadvantage on attack rolls, ability checks, and saving throws that involve Strength or Dexterity.
76-85	The character suffers from partial amnesia. The character knows who he or she is and retains racial traits and class features, but doesn’t recognize other people or remember anything that happened before the madness took effect.
86-90	Whenever the character takes damage, he or she must succeed on a DC 15 Wisdom saving throw or be affected as though he or she failed a saving throw against the confusion spell. The confusion effect lasts for 1 minute.
91-95	The character loses the ability to speak.
96-100	The character falls unconscious. No amount of jostling or damage can wake the character.

Indefinite Madness

d%	Flaw (lasts until cured)
01-15	“Being drunk keeps me sane.”
16-25	“I keep whatever I find.”
26-30	“I try to become more like someone else I know adopting his or her style of dress, mannerisms, and name.”
31-35	“I must bend the truth, exaggerate, or outright lie to be interesting to other people.”
36-45	“Achieving my goal is the only thing of interest to me, and I’ll ignore everything else to pursue it.”
46-50	“I find it hard to care about anything that goes on around me.”
51-55	“I don ‘t like the way people judge me all the time.”
56-70	“I am the smartest, wisest, strongest, fastest, and the most beautiful person I know.”
71-80	“I am convinced that powerful enemies are hunting me, and their agents are everywhere I go. I am sure they’re watching me all the time.”
81-85	“There’s only one person I can trust. And only I can see this special friend.”
86-95	“I can’t take anything seriously. The more serious the situation, the funnier I find it.”
96-100	“I’ve discovered that I really like killing people.”

Curing Madness

A calm emotions spell can suppress the effects of madness, while a lesser restoration spell can rid a character of a short-term or long-term madness.

Depending on the source of the madness, remove curse or dispel evil might also prove effective. A greater restoration spell or more powerful magic is required to rid a character of indefinite madness.

Optional Madness System Modifications

This system is an addendum to the normal madness system and adds both complexity and options to your game. You can use some or all of this system, and the list of insanities is handy for use even if you ignore the system rules within.

Madness Events

DC	Event
DC 8	Surprised to find a mangled animal carcass.
DC 11	Surprised to find a human body part.
DC 13	Surprised to find a human corpse, finding a stream flowing with blood.
DC 14	Finding a mangled human corpse, awakening trapped in a coffin, seeing a ghoul.
DC 15	Witnessing a friend’s violent death, meeting someone you know to be dead.
DC 16	Experiencing extreme pain, seeing a corpse rise from its grave.
DC 20	Seeing an evil deity, being the only survivor of a large-scale massacre.

New Category-Permanent Insanity

A character who gains any level of insanity gains 1 point of madness. That point of madness must be removed through some kind of therapy or magic.

Someone who gains 6 madness points becomes permanently insane. You can adjust this number up and down as you like depending on the nature and grittiness of the campaign. A permanently insane character becomes an NPC under the control of the GM. A character who has gone permanently insane can never be normal again. He is forever lost in his own world and from the reality of the environment that surrounds him. The character may be a ravening lunatic or outwardly indistinguishable from a normal person; however, the character has fallen into a deep, internal corruption by searching forbidden knowledge.

A GM may use Table 1-5: Random Indefinite Insanity to outline the disorder a permanently insane character suffers.

Expanded Madness Tables

These tables can offer some alternatives.

Indefinite Madness

The following disorders are examples of permanent insanities that might afflict a character. Consider them as types of indefinite madness that are available in place of the offered tables. They may also represent a deeper permanent madness, though such choices are left to the GM as they decide how to run the character as an NPC.

Short-Term Madness

d%	Effect (lasts 1d10 minutes)
01-20	Character faints (can be awakened by vigorous action taking 1 round; thereafter, the character is shaken until the duration expires).
21-30	Character has a screaming fit.
31-40	Character flees in panic.
41-50	Character shows physical hysterics or emotional outburst (i.e. laughing, crying, and so forth).
51-55	Character babbles in incoherent speech or in a torrent of coherent speech.
56-60	Character gripped by intense phobia, maybe cementing him to the spot.
61-65	Character becomes homicidal, dealing harm to the nearest person as proficiently as possible.
66-70	Character has hallucinations or delusions.
71-75	Characters say or do whatever those nearby say or do.
76-80	Character is gripped with a strange or deviant eating desire (dirt, slime, human flesh, and so on).
81-90	Character falls into a stupor (assumes fetal position or oblivious to surrounding events).
91-100	Character become catatonic (can stand but no willpower or interest; may be led or forced to perform simple actions).

Long-Term Madness

d%	Effect (lasts 1d10x10 hours)
01-10	Character performs compulsive rituals (constantly washing hands, praying, never stepping on cracks, and so on).
11-20	Character has hallucinations and delusions (at the discretion of the GM).
21-30	Character becomes paranoid.
31-40	Character gripped with a severe phobia (refuses to approach the object of phobia except on a successful Wisdom save [DC 18]).
41-45	Character has aberrant desires and obsessions (either with people or objects).
46-55	Character develops an attachment to a “lucky charm” and cannot function without it (treat as poisoned).
56-65	Character develops psychosomatic blindness, deafness, or the loss of the use of a limb or limbs.
66-75	Character has uncontrollable tics or tremors (disadvantage on physical ability checks).
76-85	Characters have amnesia (Disadvantage on Intelligence based checks that involve memory or gained knowledge).
86-90	Character has bouts of reactive psychosis (delusions, hallucinations, and so on).
91-95	Character loses the ability to communicate via speech or writing.
96-100	Character becomes catatonic (can stand but no willpower or interest; may be led or forced to perform simple actions).

Anxiety Disorders

Anxiety disorders generally develop from a variety of risk factors including personality, genetics, and life events that burden the character. When this anxiety builds over a prolonged period of time (especially when combating frightful creatures), the character may begin to develop an anxiety disorder.

Generalized Anxiety Disorders: The character suffers from a variety of physical and emotional symptoms that can be grouped into certain categories.

Motor Tension: The character suffers from jitteriness, aches, twitches, and so on. All attack rolls, saving throws, and ability checks involving Strength, Dexterity, or Constitution have disadvantage.

Automatic Hyperactivity: The character suffers from immense sweating, a racing heart, dizziness, clammy hands, and so on. All saving throws and ability checks have disadvantage.

Expectations of Doom: Anxieties culminate into a fear and an anticipation of misfortune. All attack rolls and ability checks have disadvantage.

Vigilance: The character suffers from distractions, inability to focus, insomnia, and so on. All saving throws and checks involving Intelligence, Wisdom or Charisma have disadvantage.

Agoraphobia: The character has a fear of open places. The character becomes very nervous outside familiar surroundings and must make a DC 15 Wisdom save in order to leave home or engage socially. The character may also develop a related phobia, such as uranophobia (fear of the sky), baraphobia (fear of the loss of gravity), or xenophobia (fear of strangers).

Obsessive-Compulsive Disorder: This malady develops into two forms: obsessive thoughts or compulsive actions. Some characters may exhibit both.

Obsessions: The character cannot help thinking about an idea, image, or impulse incessantly, often involving violence and self-doubt. Obsessive impulses pose dangerous situations when coupled with auditory hallucinations. There might be “voices” urging the character to take a dangerous or aggressive course of action.

Compulsions: The character insists on performing ritual actions, such as locking and unlocking doors, before entering or leaving their apartment. The need to perform these actions are so great, a character may ignore their survival in order to perform these actions. Performing a ritualistic compulsion lasts 1d10 rounds.

Phobia or Mania: A character afflicted by a phobia or a mania persistently fears a particular object or situation.

Phobia: A DC 15 Wisdom saving throw is required for a character to be able to force themselves into (or remain within) the presence of the object of their phobia. On a success, the character has disadvantage on attack rolls and ability checks relating to the object. On a failure, the character is frightened and must flee from the object of the phobia.

Philia: Philias are rarer than phobias. A character affected by a philia is inordinately fond of a particular stimulus and takes great pains to be with or near it. For example, a character with Hematophobia has a fear of blood while a character with Hematophilia has an unhealthy attraction to the act of bleeding. Resisting the impulse to indulge their mania or philia is a DC 15 Wisdom saving throw.

Dissociative Disorders

A character who becomes dissociative suffers from a lack of connection to thoughts, memories, feelings, actions, or sense of identity. Certain ordeals are so horrifying for the character that it becomes too terrible to remember.

Dissociative Amnesia: This is the inability to recall important personal information by trying to avoid unpleasant memories or events. The character must make a DC 20 Intelligence check to recall such details or the cause of amnesia. This check can be tried once per day after benefiting from a long rest. At the GM’s discretion, this may or may not affect a Wizard’s ability to memorize and prepare spells, but it is more likely than not that a wizard is not denied their spellcasting just as they retain their ability to perform other skills or tasks with no problem.

Dissociative Fugue: The character flees from home or work and cannot recall their past. Characters may assume a new identity.

Dissociative Identity Disorder: This is the infamous multiple personality disorder that has provoked the production of many films and books. Each personality a character harbors has a distinct name, behavior, and possibly, even gender. The player needs to keep track of each of the character’s different personalities (each character has the same ability scores and games statistics, but different goals, outlooks, attitudes and so on).

Impulse Control Disorders

These disorders include compulsive gambling, pathological lying, kleptomania, and pyromania.

Mood Disorders

These affect the character’s outlook and attitude to the point where it impinges on their abilities.

Depression: This disorder may include symptoms of weight gain or loss, too much or too little sleep, persistent feelings of guilt or worthlessness and can lead to hallucinations, delusions, stupor, or thought of suicide. The character will continue to accrue levels of exhaustion while suffering from depression until they reach 5 levels. These levels cannot be removed by normal or magical means until the underlying issues have been addressed. The character only dies from exhaustion if they have received 6 levels of exhaustion that are from a source outside of this mental illness.

Mania: The character possesses a constant euphoric or irritable mood. This includes talkativeness, great delusional self-esteem, no need for sleep, easily distracted, and so on. A character rolls a d20 at the start of their turn. On a natural 1, they lose focus and take a random action that does not involve attacking or helping allies, such as picking flowers or dancing a jig.

Bipolar Mood Disorder: The character changes between the two mood states staying in one mood for weeks at a time or rapidly switching from one to another without notice.

Personality Disorders

These disorders cause an unpleasant behavior, making it difficult for characters to interact with others. The character has disadvantage all Charisma-based checks. Especially bad checks can sometimes lead to creating hostile relationships with NPCs.

Psychospecies Disorders

Characters with this disorder might believe they are a different type of creature: animal, undead, aquatic, and so on.

Schizophrenia Disorders

Characters suffering from this disorder suffer a break from reality. Symptoms include hallucinations, delusions, and cognitive impairment. Characters with this impairment have disadvantage to pierce illusions or avoid the effects of illusion school spells.

Sleep Disorders

Insomnia and narcolepsy are two of many types of sleeping disorders. These disorders cause a disturbance in the character’s daily activities. Characters performing demanding tasks such as engaging in combat or casting a spell may, when stressed, need to make a DC 15 Constitution saving throw to stay awake and not put themselves in a dangerous situation.

Somatoform Disorders

These disorders are diagnosed when a character suffers from physical symptoms without actual physical injury or disease.

Somatization Disorder: The character suffers from a physical ailment or disease-like effect. Symptoms can include dizziness or impotence to blindness and intense pain. The character does not believe that their symptoms represent a specific disease. Treat as poisoned.

Conversion Disorder: The character has dysfunctions that suggest a physical disorder, though involuntary, the symptoms actually provide a way for the character to avoid some undesirable experience. Treat as poisoned.

Substance Abuse Disorders

Characters with a substance abuse disorder find comfort in using a particular drug. This includes alcohol, amphetamines, cocaine, hallucinogens, marijuana, and so on. Characters should feel a daily personal struggle and Wisdom saving throws might be used to resist or succumb to such cravings.

When sober, the character must make a Constitution saving throw after benefiting from a long rest. On a failure, the character is poisoned. If the character fails by 5 or more, they are intensely physically ill and do not gain the benefits of the long rest. This saving throw must be made until the character is free from the disorder or they indulge in the substance.

Personality Disorders

Here is a list of potential personality disorders that might otherwise not seem like insanities, but could be spun that way, especially if they become severe or overriding personality traits.

• Antisocial Reckless behavior, habitual liar, and so on.
• Avoidant Low self-esteem or socially withdrawn.
• Borderline Impulsive or unable to control.
• Compulsive Perfectionist, authoritarian, or indecisive.
• Dependent Lacks self-confidence or subordinate.
• Histrionic Craves attention and excitement.
• Narcissistic Craves attention and admiration.
• Passive-Aggressive Stubborn and deliberately inefficient.
• Paranoid Jealous, humorless, or secretive.

Removing Insanity Without Magic

While the onset of insanity might be a slow crawl into crippling madness, some games can deal with the slow mental healing process. In such cases, insanity can still exact a heavy toll, but he slowly reversible through hard work.

Story Rewards

The GM may reward players by removing an insanity should they foil a great horror or other evil enterprise. This may even coincide with gaining a level or completing a campaign arc.

Mental Therapy

To give useful mental therapy, a therapist must have the Medicine skill. Intensive treatment can remove insanities from the troubled character.

Receiving treatment that is a downtime activity.

A typical insanity can be cured after 100 days of treatment. This number can be modified depending on the needs of the campaign, as well as the intensity of the insanity. If a character is suffering from an especially long bout of temporary insanity, mental therapy can potentially reduce or remove the temporary insanity, as outlined below.

Medicine Skill

Immediate Care: When someone suffers an episode of temporary insanity, a therapist can bring them out of it by making a DC 12 Wisdom (Medicine) check. Doing so takes roughly 10 minutes of effort.

Short Term Care: A therapist can also use immediate care to stabilize a character suffering from a bout of symptoms related to their indefinite insanity. On a successful DC 14 Wisdom (Medicine) check the character can suppress the effects of the indefinite insanity for up to 4d6 hours. This treatment generally takes an hour of effort and counts towards one day of mental therapy towards permanently removing the insanity.

Long-Term Care: Providing long-term care means treating a mentally disturbed person for a day or more in a place away from stress and distractions. A therapist must spend 3 hours per day doing nothing but talking to the patient. If the therapist makes a DC 16 Wisdom (Medicine) check at the end of this time, the patient makes two days worth of progress towards removing a specific insanity, or one day’s worth of progress towards removing two insanities. If the therapist fails by 5 or less, the patient still received the benefits of short-term care. A therapist can tend up to six patients at a time; each patient beyond the first adds 3 hours to the total time per day that must be devoted to therapy. The check must be made each day for each patient. A roll of 1 forces the therapist to make a DC 12 Wisdom saving throw against madness.

NPCs & Sanity

While most insanities can be cured by player agency, curing mental impairments for non-player characters may be a different process, and take a different kind of investment of player character resources.

While treatment of temporary insanity on an NPC can end with a moment of consultation and a quick Medicine check, treatment of permanent insanity is pointless since a character can never recover regardless of the therapist or facility.

After 1d6 months, if undisturbed by further trauma and with an agreement with the Game Master, an indefinitely insane nonplayer character finds enough mental balance to reenter the world.

There are three kinds of care that may help the character remove an insanity during this recovery period. The type of care a character receives are based on the resources expended towards care.

Private Care

This involves the character finding care at home or in some friendly environment (i.e. a church or the home of a wealthy relative or friend) where constant vigilance and nursing are available. It is a place where personal care is undistracted by the needs of competing patients.

If mental therapy or alchemical medications are available, roll d% for each game month that one or the other is used. A result of 01-50 is a success: remove an indefinite insanity. On the result of 51-100, the healer fumbles the diagnosis or the character rejects the alchemical treatments. He or she makes no progress is made that month.

Benefiting from this treatment is considered to be a wealthy lifestyle, and either the character or a benefactor must pay the daily associated costs. It should be noted that despite the lifestyle costs, a character may or may not benefit from the normal bonuses associated with this lifestyle.

Institutionalization

Commitment to a good insane asylum is the next best alternative. Therapy using the Medicine skill is usually the only treatment available, however, primitive institutions might undermine progress towards treatment.

Roll d% for each game month a character is in the care of an institution. A result of 01-40 is a success: remove one indefinite insanity. On the result of 41-100, the NPC rebels against the environment, and no progress can be made that month.

An especially bad asylum is likely to cause more insanity, eventually leading to permanent insanity.

Benefiting from institutionalization is considered a squalid lifestyle, which might be paid by a friend or relative, though often is paid for by some function of the city or kingdom that maintains the institution. In some cases, the institution keeps patients in wretched conditions and gains money from some exploitative aspect of the asylum’s operational procedure, such as selling the hair of patients to wig makers.

Wandering and Homeless

If the two previous cares are not available, an insane NPC may end up homeless, babbling incoherently as he or she struggles for survival. Such a character makes no progress unless he or she is able to join a group of the homeless and find at least one friend among them. To find a friend after joining such a group the NPC can make a DC 15 Charisma (Persuasion) check once per month. If a friend appears, the affected character removes an indefinite insanity after 6 months, as long as they are not exposed to stress within that time.

For each game month during which an insane NPC lives as a derelict, roll d%. On a result of 01-99, the character survives. On a result of 100, the NPC dies as the result of disease, exposure, or violence, or is rendered permanently insane.

Fantasy Settings and Insanity

In a traditional fantasy campaign based on a medieval setting–or prior–adequate treatment for those suffering from mental illness looks bleak.

They are essentially two venues a character has available in getting treatment: go to a monastery or wander.

A monastery is a refuge away from the world and is a place where a character can peacefully collect their thoughts. Some monasteries dedicated themselves wholly to this cause. In order to enter into a monastery, one must give the Abbot all of his or her possessions. This is used to support the monastery and the new addition.

Use the same rules for Institutionalization. A monastery is less likely to abuse its patients, and will generally not charge for their services, and are more disposed to show compassion to their patients.

Alchemical Treatments in a Fantasy Setting

In a fantasy game, the Game Master should decide whether rare herbs and alchemical substances can provide the same benefits that modern psychiatric drugs can deliver. Therefore, a Game Master needs only decide how easily he wants characters to overcome insanity effects. Once the desired tone of the campaign is known, the Game Master can determine whether alchemical treatment is available.

You may decide that this variant assumes that skilled alchemists can create substances that offer the same benefits that psychiatric drugs can provide.

However, you may feel that, like real-world history, very few alchemists bothered brewing poultices for curing the mentally ill, but instead tried to create a formula of turning lead into gold for their rich patrons.

As long as a character can afford the correct herbs and alchemical substances and is able to ingest them, the symptoms of indefinite insanity can be ignored.

Ingesting these alchemical substances and drugs does not make a character immune or even particularly resistant to future insanity. A DC 25 Intelligence (Alchemist’s supplies) check is needed to accurately prepare the correct herbs and substances and administer the correct dosage.

Long-term alchemical treatment can remove indefinite insanities, just as the use of the Medicine skill can. Each day that the medication is taken is treated as a day of downtime towards removing the insanity.

Receiving the benefits of alchemical treatment are expensive, and can cost anywhere from 10- 100 gold per daily dosage. A character can benefit from both treatments with the Medicine skill and alchemical treatment.

Removing Insanity with Magic

The way insanity and magic healing interact can greatly affect the feel of your game. At one extreme, the GM can rule that magic can easily cure insanity, in which case insanity becomes little more than a specialized condition like frightened or poisoned. In such a case, characters can usually restore themselves with a day or two of rest and spellcasting.

At the other extreme, the campaign might be structured so that magical healing can do little or nothing to remove insanity, and even powerful divine spellcasters capable of curing the most deadly physical malady shy away from those encounters that might inflict mental trauma. The spells that can potentially remove indefinite insanity are discussed below.

The Game Master should feel free to choose which of these spell effects are present in the game, but once established, these effects should not be changed in mid-campaign.

Keep in mind that these rules are in place of the rules in the SRD regarding the effect of magic on insanity, but mostly coincide with the way that those rules work.

Calm Emotions: This spell cannot directly remove an insanity, but it can temporarily mitigate the effects of temporary or indefinite insanity. While the spell is in effect, the targets act calmly and ignore behavior changes caused by temporary or indefinite insanity. This spell has no effect on those suffering from permanent insanity.

Heal: In addition to its normal effects, heal removes all forms of temporary insanity. You may choose to allow this spell to remove one indefinite insanity per casting, in addition to its other effects. This also applies to the mass heal spell.

Mind Blank: While the spell is in effect, the subject automatically succeeds at all saving throws against madness.

Miracle: This spell can remove all insanities. Miracle even heals permanent insanity. This effect should be viable even in a campaign where magic does not normally affect insanities.

Restoration, Greater: If the caster chooses, greater restoration can remove all short-term and long-term insanities, one indefinite insanity, or permanent insanity, rather than the normal effects of the spell.

Restoration, Lesser: If the caster chooses, lesser restoration can remove all-short term insanity or long-term insanity instead of its normal effects.

Wish: see Miracle.

Removing Magical Healing

As a function of your campaign, you may not want for spells to remove madness. Though they are powerful resources, they are nonetheless easily acquired by most adventurer groups, eventually trivializing insanity in general for the adventurers and their allies.

You should consider instead allowing for spells to be effective in a slow and protracted process of removing insanity, with daily castings over many days (a perfect downtime activity) to remove a given madness, with deeper madnesses requiring longer amounts of time. This way the madness can still be cured but represents a deep commitment from a healer or spellcaster that could potentially be a source of madness itself.

If you remove magical healing, make sure that there are other avenues that will help mitigate or remove insanity, as it could quickly cripple your players in long-term campaigns.