It is a contemporary axiom that the financial and human resources devoted to the care of the mentally ill rarely keep pace with societal need. This reflects not simply the problem of expectations outstripping resources common to most aspects of modern medicine, but a more deep-seated cultural and theological discomfort with the very notion of mental disorder which, if by no means uniquely American, has arguably been exacerbated within the specific cultural context of North America. In an approach reminiscent of Jenny Franchot's Roads to Rome: the antebellum Protestant encounter with Catholicism (1994), Heather Vacek supplies a fascinating account of the erosion of clerical pastoral care of the mentally disturbed in favour of ‘medical’ care during the nineteenth century, and its partial restoration in the twentieth. Where Franchot offered the conversion stories of four prominent American Protestants as a coda to her study, however, Vacek grounds her narrative in the life stories of five individuals (two clergymen, two laymen and one laywoman) who sought to affirm, whether as clergy, physicians or social reformers, the importance of care for those troubled by mental disorders. As befits a scholar charged with clergy formation, Vacek is also concerned with the contemporary pastoral implications of the historical process and concludes with a reflection on the theology of hospitality and its role in overcoming social stigma. While the chapters devoted to Cotton Mather, Benjamin Rush and Dorothea Dix feel somewhat disconnected from the grand sweep of her narrative, Vacek does demonstrate how the social and cultural changes underway during the nineteenth century contributed to the shift from community-based to institutional care and from pastoral to medicalised approaches as well as discussing the influence of European initiatives in mental health care, most notably the York Retreat model. (pp. 48–9, 70) Arguably the most cohesive chapters of Madness, however, are those devoted to the careers of Anton Boisen and Karl Menninger, particularly Boisen's role in championing what would later become clinical pastoral education, a key component of present-day seminary formation, and Menninger's innovative work at the Menninger Clinic in Topeka and contributions to post-war ‘mental hygiene’ initiatives. Despite its innovative approach to its subject matter, the volume does prompt some minor criticisms. While it promises insights into American ‘Protestant’ responses, it is a largely Presbyterian (Rush, Boisen and Menninger) and Congregationalist/Unitarian (Mather and Dix) perspective that is reported. Given the centrality of Methodism to the American Protestant mainline, the absence of Methodist voices from the story arguably deserved some discussion, if only to explain why American Methodists might have held aloof. In light of Vacek's generally critical verdict on the success of congregational and community-based approaches to mental health care after 1960 (p. 141), moreover, it is surprising – particularly given her affiliation with Pittsburgh Theological Seminary – that she makes no reference to the Pittsburgh Pastoral Institute, an interfaith counselling and psychotherapy centre supporting congregations and community initiatives since 1964. Nevertheless, Madness remains a text that will be read profitably both within the academic community and outside it.