Clinical and cognitive insight in schizophrenia and their relationship with neurocognition and metacognition: a narrative review

Impaired insight in schizophrenia is consistently associated with poorer treatment adherence, more frequent hospitalization, and worse functional outcomes, yet the cognitive mechanisms that account for impaired insight remain incompletely specified. The neurocognitive model has long been the dominant explanatory framework but accounts for only a small fraction of the variance in clinical insight. This review synthesizes evidence on clinical and cognitive insight in relation to neurocognition and metacognition, identifies integrative metacognition as the principal explanatory bridge between basic cognitive resources and illness awareness, and develops the translational implications of this organization. Insight is treated as a multidimensional construct that includes clinician-rated awareness of illness and the metacognitive evaluation of one’s own beliefs. Metacognition is shown to encompass distinct construct families with different bearings on insight, of which the integrative tradition shows the most theoretically central and empirically robust associations with clinical insight. Converging but largely indirect evidence is consistent with a multi-factor model in which integrative metacognition is hypothesized to partially mediate the relationship between neurocognition and clinical insight, while cognitive insight functions as an adjacent construct that overlaps with but does not exhaust metacognitive variance. The insight paradox is incorporated as a structural feature of the model, with internalized stigma possibly moderating whether heightened awareness translates into adaptive engagement or into depression and reduced quality of life. Interventions that target metacognitive processes, including Metacognitive Training and Metacognitive Reflection and Insight Therapy, produce measurable improvements in insight outcomes, whereas approaches without explicit metacognitive targets show limited and inconsistent effects. Longitudinal designs, mediation-focused intervention trials, and the integration of emerging candidate mechanisms such as mental time travel are proposed as priorities for consolidating the model. Literature was identified through searches of PubMed, PsycINFO, Embase, Web of Science, and Scopus up to May 2026, focusing on recent peer-reviewed work in adult schizophrenia-spectrum populations.