Chapter 9, ''Despair'' / ''Karma'' takes place roughly two hours until dawn. The player takes control of Mike as he walks through the Sanatorium, Ashley as she, Sam, and whoever is alive between Chris and Emily, make their way to the Sanatorium; Chris, if he was left behind and Sam searching for Mike. Jess also makes her first physical appearance since Chapter 4; if she is still alive at this point, waking up from her unconscious state.
- The chapter's title depends on the first choice in the Eighth Therapy Session.
- If you choose "They hurt me", you'll get Karma.
- If you choose "I didn't hurt anyone", you'll get Despair.
- This marks Jessica's first appearance since Chapter 4.
- Not being quick enough in decisions will cause Mike to be attacked, and the screen to go black, but he cannot actually die in this part.
- This chapter has a total of 11 collectibles able to be found.
- Two of them can be found in Chapter 5.
- With the repeated clues, this chapter has the fourth most number of collectibles able to be found.