This systematic review (s=98) examining psychedelic-catalysed insight found that 86% of studies showed insight was linked to therapeutic improvement, with insight being dose-dependent and significantly higher than placebo in 93% of comparative studies, suggesting insight may be a key mechanism in psychedelic therapy.
Background
Insight - a sudden change in understanding or perspective that feels true or reliable - is a common occurrence during psychedelic experiences, and often considered by clinicians and patients to be central to their therapeutic value. However, their occurrence and role has not been systematically assessed.
Objectives
We reviewed all peer-reviewed studies that published data on insight catalysed by a classic psychedelic at psychoactive levels, to elucidate several aspects of psychedelic-catalysed insight, including its prevalence, relationship to dose, time-course, and relationship to therapeutic outcomes. Risk of bias was assessed regarding selection, reliability, causality, and transparency.
Findings
The final database and key bibliography searches were completed on July 13, 2024. We screened 741 abstracts and included 98 studies (40 survey, 58 interventional). Insight was positively correlated with psychedelic dose, and was significantly higher following psychedelics in 43 of 46 (93%) studies that presented a comparison to a placebo condition. Crucially, 25 of 29 studies (86%) found that insight was associated with therapeutic improvement, and this relationship was often stronger than mystical-type experience, which has received more research attention.
Interpretation
This review indicates that psychedelic-catalysed insight is associated with therapeutic improvement, suggesting its importance for clinical practice and for understanding the mechanisms of psychedelic therapy.
Limitations
Heterogeneous study designs and operationalisations of insight precluded a meta-analytic summary. Publication bias and selective reporting is possible, given insight was typically not a primary outcome of the included studies.
Papers cited by this study that are also in Blossom
Agin-Liebes, G. I., Lancelotta, R., Uthaug, M. V. et al. · ACS Pharmacology and Translational Science (2021)
Agin-Liebes, G. I., Malone, T., Yalch, M. M. et al. · Journal of Psychopharmacology (2020)
Aicher, H. D., Mueller, M. J., Dornbierer, D. A. et al. · Frontiers in Psychiatry (2024)
Barba, T., Buehler, S., Kettner, H. et al. · BJPsych Open (2022)
Psychedelic-assisted experiences at psychoactive doses commonly produce a range of acute subjective effects that have been linked to therapeutic benefit, including connectedness, emotional breakthrough, ego-dissolution and mystical-type experiences. Among these subjective changes, many users and clinicians report sudden, confidence‑laden changes in understanding—termed "insight"—which the authors define here as the sudden emergence of a change in perspective accompanied by clarity or certainty. Earlier studies have reported correlations between acute insight ratings and improvements in wellbeing, depression, anxiety and substance use, but insight itself has not been the subject of a comprehensive, systematic synthesis. Kugel and colleagues set out to fill that gap by conducting the first systematic review focused on psychedelic‑catalysed insight. The review aimed to characterise the prevalence of insight after psychoactive doses of classic serotonergic psychedelics, its relationship to dose, its time-course, and its association with therapeutic outcomes, and to compare insight with mystical‑type experiences as predictors of clinical benefit. The investigators also assessed risk of bias across included studies and made their protocol and materials openly available.
The review followed a pre-registered protocol (PROSPERO CRD42023405854) and PRISMA guidance. Inclusion criteria required peer‑reviewed human studies in English reporting primary quantitative data on insight‑related constructs following psychoactive doses of classic serotonergic psychedelics (LSD, psilocybin, DMT, ayahuasca, 5‑MeO‑DMT or mescaline). All study designs were eligible, including randomised controlled trials, other interventions and survey studies. The search iteratively combined psychedelic substance terms with insight‑related terms and instrument names; the authors reran searches as new psychometric instruments were identified. Seven instruments providing insight data were identified and are documented in the supplementary materials. Screening was performed in Covidence with dual review at key stages: the primary reviewer screened all records and a secondary reviewer screened random subsamples, with consensus and arbitration procedures described. Data extraction captured study design and sample characteristics, drug and dose, timing and scores on insight measures, data sufficient to compute effect sizes for active versus placebo conditions where available, and correlations between insight and mental‑health outcomes; 20% of included studies were double‑checked for extraction accuracy. Where necessary, scores were standardised to conventional units for each scale. Because the included studies were heterogeneous in measures, designs and populations, the protocol did not specify a meta‑analysis. Instead, synthesis combined vote‑counting for prevalence and outcome associations, condition‑level correlations for dose–response relationships, graphical displays of time‑course where multiple timepoints existed, and tabular summaries of associations between acute insight and therapeutic outcomes. For comparisons between insight and mystical‑type experience as predictors, the authors used vote‑counting and, where data permitted, statistical tests (Steiger z‑tests) comparing dependent correlations. Risk of bias was assessed using an adapted ten‑domain instrument tailored to the heterogeneous literature; studies were rated low, medium or high risk on each domain. The primary reviewer completed the RoB assessments and a secondary reviewer checked 20% of studies. Agreement thresholds and procedures for resolving discrepancies were prespecified and reported.
Searches and screening produced 98 included studies from an initial set of 741 unique records after deduplication. The final corpus comprised a mixture of designs: in Discussion the authors report 26 retrospective surveys, 14 prospective surveys, 44 randomised controlled trials and 14 non‑randomised intervention studies. Substances studied included psilocybin (the most frequently represented) and LSD among others. Measures of insight varied across studies. Eighty‑five studies used standardised instruments while 13 used unconventional measures. The 5D/11D‑ASC Insightfulness subscale was the most commonly reported measure (60 studies), followed by the single‑item JHU Psychological Insight (JHU‑PI; 15 studies), the Psychological Insight Questionnaire (PIQ; 14 studies) and the Noetic Quality subscale of the MEQ43 (11 studies). These instruments differ in whether they emphasise phenomenology (certainty, profundity) or content (psychological themes). On prevalence, psychedelic administration at psychoactive doses was consistently associated with insight experiences. Of 46 studies that directly compared classic psychedelics (without pretreatment) to placebo, 43 studies (93.5%) found significantly higher insight scores in the psychedelic condition. A large study cited by the authors reported that 99% of 886 participants indicated they gained insight immediately after a psychedelic experience. The three null comparator studies used a 26 μg LSD dose, which the authors note sits near the microdose threshold and may explain the lack of difference. Insight was positively related to dose. Fifty studies reported dose‑specific data without pretreatment, and across drug–measure combinations higher dose conditions tended to have higher insight scores. For psilocybin in RCTs, the authors report a moderate to strong positive correlation between dose and the 11D‑ASC Insightfulness factor (r = 0.64, 95% CI [0.37, 0.81]). Thirteen studies reported multiple psychoactive doses within a study; 12 of these (92%) observed higher insight ratings at higher doses. Exploratory condition‑level regressions suggested that clinical populations may report higher insight ratings across doses than non‑clinical populations, although the authors attribute this to potential systematic differences such as greater psychotherapeutic support in clinical trials. Longitudinal data on insight ratings were sparse. Most interventional and prospective survey studies measured insight only once: 92% measured insight at a single timepoint, and 88% of those collected that measurement within 24 hours of the experience. Only eight studies reported insight at more than one timepoint. Available evidence indicates that many acute insight ratings persist over time rather than being rapidly devalued; examples include short‑term increases in insight ratings after psilocybin and higher Noetic Quality ratings in a 25‑year follow‑up of the Good Friday Experiment compared with six months post‑session. Regarding therapeutic associations, the majority of studies found that acute psychedelic‑catalysed insight related to later clinical benefit. Across study types, 25 of 29 studies (86%) that examined the relationship reported at least some significant associations between insight and therapeutic outcomes. In randomised trials, 6 of 8 RCTs (75%) that tested the link found a significant relationship. The associations covered a range of outcomes: reductions in psychopathology symptoms (depression, substance use, trauma symptoms), improvements in processes such as reduced thought suppression and experiential avoidance, and increases in positive mental health measures (wellbeing, life satisfaction). The authors report pooled correlations calculated using random‑effects models for psychopathology outcomes (r = -0.33, 95% CI, I2 = 73%) and for positive mental health outcomes (r = 0.43, 95% CI [0.24, 0.58], I2 = 76%), noting considerable heterogeneity. When directly compared with mystical‑type experiences as predictors, insight was more strongly associated with therapeutic outcomes in a majority of studies. Of 22 studies that measured both constructs, 12 (55%) favoured insight, 5 (23%) favoured mystical‑type experiences and 5 (23%) had mixed results. Across 45 outcome comparisons, 31 (69%) indicated stronger correlations for insight. In a subset of nine studies where Steiger z‑tests could be computed for 15 comparisons, seven comparisons favoured insight, eight showed no significant difference and none favoured mystical‑type experiences. The authors caution that overlap in items (for example, Noetic Quality items appearing in mystical experience scales) complicates disentangling the constructs. Risk of bias assessments revealed variability across studies. Interventional studies had lower mean RoB scores than survey studies (M = 0.51 vs M = 0.69), with RCTs tending to score lowest (M = 0.49). RoB scores showed a modest negative correlation with year of publication (r = -0.14), indicating improvements over time, and transparency scores improved in more recent work (RoB transparency correlated with year r = -0.35). Selection bias due to unrepresentative or convenience sampling was the most common risk.
Kugel and colleagues interpret their findings as evidence that psychedelic‑catalysed insight is a common and clinically relevant feature of classic psychedelic experiences at psychoactive doses. The authors emphasise four principal conclusions: insight is highly prevalent after macrodoses; insight intensity tends to increase with dose; many people continue to regard acute insight experiences as meaningful over time; and acute insight is frequently associated with therapeutic improvement, often more reliably than mystical‑type experiences. The review situates these conclusions within prior literature by noting that the prominence of insight in psychedelic reports aligns with cultural and historical characterisations of psychedelics as epistemically revealing substances. The authors also relate their operational definition of insight to problem‑solving and psychotherapeutic literatures, distinguishing phenomenological aspects (suddenness, certainty, emotionality) from content‑focused measures (psychological themes). Key limitations acknowledged include heterogeneous operationalisations and timing of insight measures, the predominance of studies that did not make insight a primary outcome, and the resulting inability to perform a quantitative meta‑analysis on many questions. The authors note the risk of selective reporting and publication bias, and caution that strong correlations between acute experience and outcomes in trial data do not establish causality. They also highlight methodological limitations in many primary studies (lack of placebo control, inadequate blinding, small samples) that constrain causal inference. Potential harms and complexities are explicitly discussed. The investigators warn that insight experiences can be misleading, epistemically biased and, in some contexts, maladaptive; they draw attention to case reports of distress arising from compelling but erroneous revelations and to theoretical links between repeated insight‑like shifts and psychosis. To address these risks, the authors recommend future work to characterise harmful trajectories and early indicators of epistemic harms and to adapt clinical practice accordingly. For future research and practice, the authors call for improved measurement of psychedelic‑catalysed insight, including instruments that capture both phenomenological qualities (suddenness, certainty, surprise, emotionality) and a broader range of content themes. They advocate studies that link the specific content of insights to subsequent behavioural change, designs that can probe causality (for example, manipulations that minimise subjective effects), and longitudinal work to map how insight ratings and content evolve and relate to durable outcomes. Finally, the authors suggest that clinicians and researchers should broaden the focus beyond mystical‑type experiences when assessing mechanisms of therapeutic efficacy in psychedelic interventions.
This systematic review synthesised 98 studies reporting quantitative data on psychedelic‑catalysed insight. The authors conclude that insight is common at psychoactive doses, its intensity is positively correlated with dose, and many people continue to regard these acute insights as meaningful over time. Importantly, acute insight is frequently associated with therapeutic benefit across substances, study designs and outcomes, and often shows stronger associations with improvement than do measures of mystical‑type experience. The review highlights the need for better measurement, longitudinal and causal research, and clinical attention to both the potential benefits and epistemic risks of insight experiences.
High doses of classic psychedelicsproduce many different acute subjective effects, which predict therapeutic benefit to varying degrees. These include feelings of connectedness, awe, emotional breakthrough, ego-dissolutionand mystical-type experiences. Similarly, many people, across a diversity of contextsfrom indigenous cultural practices to clinical trialscommonly report gaining new knowledge or understandings from their use of psychedelics. Modern psychedelic research tends to use the word insight to refer to this phenomenon, and specifically to acquisition of new understandings that are grasped suddenly and are accompanied by a feeling of certainty or confidence (we discuss formal definitions of insight below). Recently, insight has been highlighted as a therapeutic mechanism of psychedelics and psychedelic-assisted therapies. Several studies have found a correlation between acute ratings of psychedelic-catalysed insight and therapeutic benefits, including increased wellbeingreduced depressive symptoms, reduced anxiety and stress, and reduced problematic alcohol consumptionand substance use. For example,found that Insightfulness scores on the 11D-ASC were correlated with reductions in depression scores five weeks later (r = -.57, p = .01), and that out of all self-report items administered, an item from the Insightfulness factor ("I felt particularly profound") was the most highly correlated with clinical benefit (r = .581, p =.0005;. Recently, several new measures have been developed to specifically assess aspects of psychedelic-catalysed insight. Here we conduct the first systematic review of empirical findings relating to insight catalysed by therapeutic doses of psychedelics, including its prevalence, relationship to dose, time-course and relationship to therapeutic outcomes. By doing so, we aim to improve our understanding of the mechanisms underlying psychedelic-assisted therapy and thereby improve therapeutic interventions.
Insight has been the subject of scientific study for over 100 years, and appears in various domains, including problem-solving and creativity research, psychotherapeutic research, contemplative science, and cognitive neuroscience. In all these fields, insight is defined not just in the colloquial sense of an accurate and deep understanding, but as a particular type of cognitive process accompanied by a particular phenomenology. Some approaches have focused on phenomenological aspects, defining insight as the immediate certainty or confidence in the veridicality of a new understanding, exemplified by "aha", "Eureka" or "lightbulb" moments. Other approaches have focused on cognitive aspects, defining insight by the sudden restructuring of mental representations that permit a new interpretation or solution to emerge. While the relationship between the cognitive and affective aspects of insight remains a topic of ongoing study in problem-solving research, cross-disciplinary studies suggest that the affective aspects of insights are less variable across contexts than the J o u r n a l P r e -p r o o f cognitive aspects. As such, in this review, we focus on insight phenomenology, defining insight as the sudden emergence of a change in understanding or perspective accompanied by a feeling of clarity or certainty. Insight phenomenology is central to its definition and identification in all domains where insight is studied. In the problem-solving literature, where insight has been most rigorously studied, researchers have increasingly moved towards identifying insight on the based on self-reported phenomenology, rather than the type of problem used to elicit it (i.e., insight occurs when a problem, identified a priori as requiring insight, is solved). Further, insight problem-solving research is increasingly capturing the different affective dimensions of the insight, rather than unidimensional global reports of whether an insight was experienced. This literature shows that insight is typically accompanied by a sense of surprise, positive emotionality, and a sense that the insight was induced by subconscious processes, rather than resulting from effortful or intentional cognition alone. As we define it, insight is not just an improved understanding or a subjective component of correct problem-solving, but an important type of cognitive process. In the problem-solving literature, insight is generally considered to be a distinct cognitive process, and is contrasted with analytical, incremental, problem-solving processes. More generally, the feeling of insight has been proposed to act as a metacognitive heuristic, capturing attention and thereby aiding the selection of ideas or perspectives based on prior learning and context. Insight may also lead a person to change which aspects of a problem or situation they find salient (sometimes J o u r n a l P r e -p r o o f described as seeing the problem through "new eyes"), and increase motivation for action. Insight, and related processes, appear in various domains of cognitive science. Insight is described both in (a) psychotherapeutic research, where distinct moments of insight are common, regardless of whether the theoretic approach of the therapist emphasises insight, and in (b) contemplative or meditative traditions, where it refers to the often sudden feeling of realisation of certain predefined teachings. Analogous processes are also described in learning (e.g., the notion of "conceptual change";, flow states, and cognitive development (e.g., Piaget's notion of accommodation.
Insight is a regularly reported feature of psychedelic experiences. Insight is a common motivation for naturalistic psychedelic use, and people often credit the improvements in wellbeing or behaviour following psychedelic use to the insights they gain. The affective aspects of insight, highlighted within the problem-solving literature, are often experienced intensely following the administration of psychedelics. People often report gaining new understanding (i.e., clarity) in a way that is felt to be directly perceived or received rather than intellectually worked out (i.e., sudden), and accompanied by such a sense of authority that the new understanding can be held with almost unshakable conviction (i.e., certainty). These aspects of acute psychedelic experience are sometimes referred to as the noetic quality. Reflecting the centrality of insight to psychedelic experience, all the most prominent scales used to assess psychedelic phenomenology include items referring to insight and J o u r n a l P r e -p r o o f related subjective elements (see Tablefor example items), including the Altered States of Consciousness Rating Scales (all versions: APZ, OAV, 5D-ASC and 11D-ASC), Phenomenology of Consciousness Inventory, Hallucinogen Rating Scale, and Mystical Experience Questionnaires (MEQ43 and MEQ30). Additional measures have recently been developed to assess certain types of insight that are occasioned by psychedelics. The Psychological Insight Scale (PIS;and the Psychological Insight Questionnaire (PIQ;are both measures of "psychological insights" catalysed by psychedelic experiences. Similarly, the Acceptance/Avoidance-Promoting Experiences Questionnairecaptures psychedelic-catalysed insights related to alterations in psychological flexibility.
There is a need for a comprehensive and integrated review of research on psychedeliccatalysed insight for two main reasons. First, despite the high level of academic interest in psychedelic-catalysed insight, there has been no comprehensive review of the empirical research to date. Second, psychedelic research has increasingly focused on specific types of insights (e.g., "psychological insights" about one's thoughts, emotions, and behaviours, but not "mystical insights" concerning metaphysical, supernatural or spiritual topics) or aspects of insight (e.g., only evaluations of insightfulness without capturing the accompanying affective aspects), rather than studying the phenomenon of insight as a whole (see. Consequently, research on psychedelic-catalysed insight risks being undermined by construct under-representation and the jingle-jangle fallacies. As such, we include in this review not only scales that explicitly measure insight, but also scales that measure defining aspects of insight experiences (such as the felt certainty that is central to Noetic Quality scales). We believe that studying insight as a type of cognitive process catalysed by psychedelics will bring greater coherence and clarity around the role of J o u r n a l P r e -p r o o f psychedelic-catalysed insight, facilitate cross-pollination between psychedelic research and the cognitive science of insight, and highlight important avenues for future research. Given this rationale, this systematic review analyses empirical findings relating to insight catalysed by psychoactive doses of psychedelics (i.e., not microdoses), including its prevalence, relationship to dose, time-course and relationship to therapeutic outcomes. While not identified as a core research question in the protocol, this review also presents an exploratory comparison of insight and mystical-type experiences as predictors of therapeutic outcomes. Additionally, the limitations of the available evidence and directions for future research are discussed.
The study protocol was developed in accordance with the Systematic Reviews and Meta-Analyses guidelines (PRISMA;and registered on the International Prospective Register of Systematic Reviews (; ID: CRD42023405854). All research materials and files associated with the data (search queries, search validation set, imported databases searches, excluded studies at each screening stage, extracted data, data analysis scripts) are available at the Open Science Framework ().
We aimed to identify all peer-reviewed studies that published data on insight catalysed by a classic psychedelic at psychoactive levels. Inclusion criteria were: 1) use of 'classic' or serotonergic psychedelics (LSD, psilocybin, DMT, ayahuasca, 5-MEO-DMT or mescaline); J o u r n a l P r e -p r o o f 2) doses above the microdose range (as defined by Polito & Liknaitzky, 2022) OR if the dose was not ascertained, doses where the effects were hallucinogenic and/or involved functional impairment; 3) reporting of primary quantitative data relating to insight-related constructs (including "insight", "insightfulness", "psychological insight", and "noetic quality"); 4) use of human subjects; and 5) peer reviewed publications, written in English. All study designs were eligible for inclusion, including randomised controlled trials, other interventional designs, observational studies and prospective or retrospective survey studies. No restrictions were placed on the date of publication. Our search strategy was to identify papers that included a term in the title, abstract or keywords related to any classic psychedelic substance, plus a term anywhere in the article related to insight or instruments that capture psychedelic-catalysed insight. As additional psychometric instruments that measure psychedelic-catalysed insight were identified, the search was re-run with the name of the new instrument added to the search terms. The search terms at the start and the end of this iterative process, and the set of clearly eligible studies used to validate the search strategy, are included in the Supplementary Information. We identified seven instruments providing data on psychedelic-catalysed insight (Table). The psychometric properties and item content of the instruments are included in the Supplementary Information. Some commonly used measures that contain insight-related items, such as the Phenomenology of Consciousness Inventory (PCI) and Hallucinogen Rating Scale (HRS), were excluded as they do not have an insight-related factor, and hence, their total and factor scores do not provide information specifically about insight. Similarly, studies using the 5-Dimensional Altered States of Consciousness Rating Scale (5D-ASC), Hood Mysticism Scale, or Revised Mystical Experience Questionnaires (MEQ30), which do not typically have an insight-related factor, were only included if they published data for an J o u r n a l P r e -p r o o f alternative factor structure that included an insight-related factor (Insightfulness or Noetic Quality). J o u r n a l P r e -p r o o f All screening rounds were conducted independently by two reviewers (JK, RL). Search results from the five databases, eligible studies from the ASDB, and manual bibliography searches were imported into Covidence, where duplicates were removed, and titles and abstracts were screened for eligibility. Full text screening was conducted on the remaining studies. At each stage, the primary reviewer (JK) screened all articles and the secondary reviewer (RL) screened a random sample of 20% of the same articles, in accordance with previously published recommendations. Any disagreements during screening were resolved through discussion, and if consensus was not reached, a third reviewer (PL) arbitrated. If agreement was below a pre-specified threshold of 90%, an additional random sample of 20% of the set of articles was screened. The level of agreement between the two reviewers was 96% at the title stage, and 88% at fulltext review stage. Consequently, a second 20% sample of papers was reviewed, in which the inter-rater agreement was 100%.
Data were extracted by the primary reviewer. Another team member reviewed 20% of the included studies to confirm that data had been extracted accurately. Errors were detected in 0.3% of extracted data points, falling below the threshold of 5% that would have triggered the review of an additional random sample of 20%. Authors were contacted if the relevant data was presented but interpretation was unclear, whereas authors were not contacted when insight data was not reported. The extracted data included: study design, sample size and characteristics, drug and dose, insight-related scale scores, timing of administration of insight scale, data permitting the computation of a summary effect size between active vs. placebo conditions (where relevant), and measures of the relationship between insight scores and mental health outcomes. Where necessary, insight-related scores were converted to the conventional units for that scale (e.g., J o u r n a l P r e -p r o o f converting from a raw score to a proportion of scale maximum). Additionally, from studies that published correlations between mental health outcomes and both mystical-type experiences and psychedelic-catalysed insight, we extracted bivariate correlations between mental health outcomes and mystical-type experiences (or defining aspects of mystical-type experiences, such as ego-dissolution).
Given degree of expected heterogeneity in outcome measurements, treatment type, and trial design, a meta-analytic summary was not specified in the protocol. Instead, to inform the research question about the prevalence of psychedelic-catalysed insight, we used votecounting based on whether insight scores were statistically significantly higher in the placebo or psychedelic condition. For the research question about the relationship between insight and psychedelic dose, we calculated a correlation coefficient for each drug-measure combination, using data from all relevant conditions. By including data at the condition level rather than the study level, studies reporting insight scores for multiple high dose conditions (e.g., dose-dependence studies) contribute multiple datapoints. We graphically present only the drug-measure combinations with the most data (Figureand Figure). For the research question about the time-course of insight ratings, we graphically present the data for all studies which measured insight at more than one timepoint (Figure). For the research question about the association between acute psychedelic-catalysed insight and mental health outcomes, we present a structured tabulation of results grouped by the type of outcome variable (Table) and study design (Table). For the exploratory research question comparing insight and mystical-type experiences as predictors of therapeutic outcomes, we used vote-counting to assess the relative strength of these relationships. Specifically, we compared the strength of association of insight and mystical-type experiences with therapeutic outcomes using two criteria: a) absolute values, irrespective of J o u r n a l P r e -p r o o f statistical significance, and b) statistically significant differences, based on Steiger z-tests for the equality of two dependent correlations. Vote counting was conducted at both the outcome comparison and study levels. Studies containing comparisons of multiple therapeutic outcomes were classified as having "mixed" results if some outcomes demonstrated a stronger relationship with insight and others favoured mystical-type experiences.
Given that the studies reviewed were highly heterogeneous, we used an adaptation of the risk assessment methodology developed by, rather than common Risk of Bias assessments such as the Cochrane Collaboration tool. Studies were scored (low, medium, high risk) on ten domains, with precisely operationalised scoring guidelines for each domain (Table). After piloting, the Risk of Bias criteria in the pre-registered protocol were slightly amended to enhance the clarity and completeness of the rating criteria. The Risk of Bias assessment was completed by the primary reviewer. The secondary reviewer assessed 20% of the included studies to confirm that risk of bias criteria had been evaluated accurately. Any discrepancies were recorded and resolved via discussion. If agreement was below a pre-specified threshold of 90%, an additional random sample of 20% of the same articles were assessed for risk of bias. However, this was not triggered, as the level of agreement between the two reviewers was 93%. J o u r n a l P r e -p r o o f 3. Results
The systematic database search strategy identified 2089 papers, with another 27 papers identified from other sources. After removing duplicates, 741 unique papers had their titles and abstracts screened for eligibility. Full text screening was conducted on the remaining articles (n = 311), leading to a final sample of 98 included papers (see Figure). (32 studies, 56%) or LSD (16 studies, 28%).
Within the 98 selected studies, 85 studies used standard measures of insight, while the remaining 13 studies used unconventional measures. Most commonly, insight was assessed through items included in broad, multidimensional measures of psychedelic experience. The 5D/11D-ASC was the most used instrument that included data on insight, with its Insightfulness subscale reported in 60 studies. Other popular measures of insight included the single-item JHU -Psychological Insight (JHU-PI) measure (15 studies), the Psychological Insight Questionnaire (PIQ; 14 studies) and the Noetic Quality subscale of the MEQ43 (11 studies). J o u r n a l P r e -p r o o f
Across all study designs, psychedelic substances, and populations, psychedelic administration was consistently found to be associated with insight experiences. Of the 46 studies that presented a comparison between classic psychedelic (without pretreatment with Ketanserin or an SSRI) and placebo conditions, 43 studies (93.5%) found insight was significantly higher in the psychedelic condition. The three studies that did not find a significant difference between conditions used a 26ug dose of LSD. While above the 25ug threshold defining a "microdose", and therefore included in this review, a 26ug dose could arguably still be considered a "microdose". The ubiquity of insight experiences is further supported by the largest study to assess insight immediately after a psychedelic experience, in which 99% of the 886 participants indicated that they gained insight from their experience.
To investigate the relationship between insight and psychedelic dose, we analysed the 50 studies that reported data on insight following a precise dose of a classic psychedelic without pre-treatment with another drug (such as an SSRI or Ketanserin). Insight scores were positively correlated with dose, across all drug-measure combinations tested (Figure). For psilocybin, the substance with the most data, there was a moderate to strong positive correlation (r = .64, 95% CI [0.37, 0.81]) between dose and the Insightfulness factor of the 11D-ASC within RCTs. This is consistent with previous studies that found a similar withinstudy relationship. Insight scores for multiple psychoactive doses were reported by 13 included studies, of which 12 (92%) observed that higher doses were associated with higher insight ratings. Additionally,analysed the studies listed in the Altered States Databaseand found that higher doses were J o u r n a l P r e -p r o o f Although not pre-specified in the PROSPERO protocol, we conducted an exploratory analysis comparing insight scores between clinical and non-clinical populations. We fitted separate linear models for clinical and non-clinical populations on the drug-measure combinations with the most available data (Psilocybin-5/11D-ASC -Insightfulness: 4 groups from 3 studies and LSD5/11D-ASC -Insightfulness: 8 groups from 3 studies). These models were run at the condition level, meaning that studies reporting insight scores for multiple macrodose conditions (e.g., dose-dependence studies) contributed multiple datapoints. The regression lines for both LSD and psilocybin were higher for clinical populations across the entire range of doses. For LSD studies, clinical populations had a higher intercept (0 = 20.0, p = 0.10) and slope (1 = 0.167, p = 0.047, R 2 = 0.51), than non-clinical populations (0 = 14.6, p = 0.023; 1 = 0.165, p = 0.014, R 2 = 0.28). Similarly, for psilocybin studies, clinical populations had a higher intercept (0 = 12.8, p = 0.26 ) and slope (1 = 1.97, p = 0.043, R 2 = 0.92) than non-clinical populations (0 = 12.0, p = 0.041; 1 = 1.32, p < 0.001, R 2 = 0.40). These findings suggest that clinical populations perceive psychedelic experiences as more insightful than non-clinical populations. While there are likely to be systematic factors contributing to this difference (such as greater psychotherapeutic support provided in clinical trials), this result is consistent with a number of studies that have directly compared these
There is little data on how people's evaluation of psychedelic-catalysed insight changes over time, as insight has generally been considered as an aspect of the acute psychedelic experience. Of the interventional and prospective survey studies we reviewed, 92% measured insight only once, and 88% of those assessed insight within 24 hours of the experience. Only eight studies reported changes in the way people rate their psychedelic-catalysed insight over time (Figure). The available evidence suggests that typically, rather than being devalued over time, people continue to rate their acute experiences of insight as genuinely insightful. For example,found that ratings of insight (using items from the HRS, MEQ43, JHU -PI and 5D-ASC) increased in the week after the administration of psilocybin. Similarly, in a 25-year follow-up of the participants in Pahnke's "Good Friday Experiment" J o u r n a l P r e -p r o o f,found that Noetic Quality ratings were higher than at 6 months after the psychedelic experience. This finding, that ratings of insightfulness tend to endure long after the psychedelic experience, is consistent with research on non-psychedelic induced religious and spiritual experiences. While preliminary evidence suggests that ratings of insightfulness remain elevated long J o u r n a l P r e -p r o o f J o u r n a l P r e -p r o o f
In studies examining the relationship between clinical outcomes and both insight and mystical-type experiences (including measures of defining aspects of mystical-type experiences, such as ego-dissolution), insight demonstrated a stronger association in 12 of the 22 studies (55%). Five studies (23%) found that therapeutic outcomes were more strongly correlated with mystical-type experiences, while another five (23%), reported mixed results that varied across associated constructs. Of the 45 comparisons within these studies, 31 (69%) indicated that acute insight was more strongly correlated with therapeutic outcomes than are mystical-type experiences (Table). A subset of 28 comparisonsfavouring insight), which used standard measures of insight and mystical-type experience and presented data correlating these measures with a therapeutic outcome, is depicted in Figure. Nine studies (containing 15 comparisons) published the necessary data to statistically compare the correlations between therapeutic outcomes and both insight and mystical-type experiences using Steiger z-tests. Of these comparisons, 7 favoured insight, 8 were not statistically different, and none favoured mystical-type experiences.
The reviewed studies displayed a wide range of Risk of Bias (RoB) scores (see Table). There were several patterns related to study type and year of publication. Interventional studies had lower average RoB scores than survey studies (M = 0.51 vs. M = .69), with Randomised Controlled Trials tending to have lower RoB than any other study design (M = 0.49). RoB scores were negatively correlated with year of publication (r = -.14), indicating that the RoB has tended to be lower in more recent studies. In terms of categories of risk, selection bias was a risk in most studies, with unrepresentative and convenience sampling being common. Causality and reliability bias J o u r n a l P r e -p r o o f scores varied significantly, and were mostly associated with study designs, and not design flaws (e.g., retrospective survey studies have inherently higher risk of reliability and causality bias than randomised controlled trials). Encouragingly, studies are increasingly following open science practices and reporting their methods rigorously, as reflected in a moderate negative correlation between RoB transparency scores and year of publication (r = -.35). Ranked categories of bias risk were as follows: 1. Unrepresentative/convenience sampling (most common risk)
Experiencing a new understanding that feels true ("insight") features prominently in many reports of classic psychedelic use at psychoactive doses. Many people consider this feature to be central to the value of psychedelic substances, whether therapeutic or otherwise. Indeed, insight has been highlighted as a mechanism driving the therapeutic effects of psychedelics. To better understand the relationship between psychedelics, insight, and therapeutic efficacy, we conducted the first systematic J o u r n a l P r e -p r o o f review on psychedelic-catalysed insight. We comprehensively reviewed all available empirical research involving psychoactive doses of psychedelics to better understand psychedelic-catalysed insight's (a) prevalence, (b) relationship to psychedelic dose, (c) timecourse, and (d) relationship to therapeutic outcomes. We found 98 studies that published data on psychedelic-catalysed insight, including 26 retrospective survey studies, 14 prospective survey studies, 44 randomised controlled trials, and 14 non-randomised studies of interventions. In this section, we describe how the findings answer our research questions, comment on the methodological rigour of the included studies, offer suggestions regarding the clinical implications, and highlight fruitful directions for future research.
We identified seven instruments providing data on psychedelic-catalysed insight. These measures were used in 85 studies of the included studies, while the remaining 13 studies used unconventional measures. An overview of the seven measures is presented in Tableand item content and psychometric details are provided in the supplementary information. The 5D/11D-ASC was the most used instrument that included data on insight, with its Insightfulness subscale reported in 60 studies, followed by the single-item JHU -Psychological Insight (JHU-PI) measure (15 studies), the Psychological Insight Questionnaire (PIQ; 14 studies) and the Noetic Quality subscale of the MEQ43 (11 studies). The included measures providing data on psychedelic-catalysed insight reflect a diversity of conceptualisations of insight. Some items and measures capture the specific content of insights (e.g., "Realized how current feelings or perceptions are related to events from my past" from the PIQ), while others focus on the feelings and phenomenology associated with insight experiences (e.g., "I felt very profound" from the 11D-ASC Insightfulness). This distinction mirrors the differing approaches within problem-solving research, where insight has been defined and identified either by self-reported J o u r n a l P r e -p r o o f phenomenology or by the type of problem or cognitive restructuring undertaken. Moreover, insight ratings may also be systematically influenced by study design. Insight ratings from retrospective survey studies may reflect recollections coloured by memory biases, while those from studies of psychedelic-therapies may conflate acute insight experiences with the broader therapeutic context. Additionally, the timing of survey administration may similarly influence ratings, with surveys administered closer to dosing capturing immediate subjective states, while those administered later reflecting broader evaluative processes. Improved definition and measurement of psychedelic-catalysed insight, and how its measurement is influenced by methodological variables, are important topics for future research.
This review showed that classic psychedelic substances almost always catalyse experiences of insight at all psychoactive doses (above a "microdose"). Across differing study designs, psychedelic substances, and populations, 43 of 46 (93%) studies that presented a comparison of psychedelic and placebo conditions found insight was higher in the psychedelic condition. Our findings on the prevalence of psychedelic-catalysed insight accord well with the way various cultures have characterised psychedelics in terms of their epistemic value. For example, some Amazonian cultures refer to the plants used in the psychedelic Ayahuasca brew as "teachers". Indeed, the etymology of the word psychedelic, coined by Humphrey Osmond in 1957from the Greek words psykhē ("mind") and dēloun ("reveal"), connotes new knowledge or understanding.
Another finding was that insight scores were positively correlated with dose, across all psychedelic substances. Of the 13 studies that presented data on psychedelic-catalysed insight at multiple doses, 12 (92%) found that higher-doses of classic psychedelics were associated J o u r n a l P r e -p r o o f with higher insight ratings. Measured across studies, we found a positive correlation between insight scores and dose, for all drugs and measures of insight. For example, for psilocybin, the substance with the most high-quality data, there is a moderate-strong positive correlation (r = .67) between dose and the 11D-ASC -Insightfulness factor scores in RCTs. Interestingly, a number of studies found no difference in, or even lower, insightfulness ratings between moderate and high doses (e.g.,. This suggests that insight ratings may peak, or have a ceiling, at some dose, or be related to extra-pharmacological factors associated with the treatment or treatment population. Additionally, the historical divide between high-dose "psychedelic" and moderate-dose "psycholytic" approaches to psychedelic-assisted therapy suggests that different doses may be conducive to different types of insights. The suggestion, which is speculative and requires empirical testing, is that insight content could tend to move from the psychological and interpersonal to the mystical and metaphysical as dose increases. Further research is required to support the optimisation of dose for different therapeutic approaches.
Scant data on changes to psychedelic-catalysed insight ratings over time means that the following patterns should be treated as preliminary and in need of further verification. Only eight studies measured insight experiences at two or more time-points, with insufficient data to determine whether the performance of different insight measures varies over time. The evidence to date suggests that people continue to rate their experiences of psychedeliccatalysed insight as genuinely insightful, even years after the psychedelic experience, which is consistent with research on non-psychedelic induced religious and spiritual experiences. However, how ratings of insightfulness change over time remains unclear. Only two studies measured insight experiences at more than two time-points. J o u r n a l P r e -p r o o ffound that ratings of psychological insightfulness (JHU-PI) fell steadily but statistically non-significantly between 1 day, 3 weeks and 6 weeks after dosing, whilefound that psychological insightfulness (PIS) fell between 1 day, 2 weeks and 4 weeks after dosing in one sample, but increased in another sample. Further, no data has been published about how ratings of specific insights change over time. Characterising whether insight ratings change over time, examining whether such trajectories differ for various types of insights, and whether such changes relate to the durability of therapeutic benefit will be valuable areas for future research.
The majority of studies (86%, n = 25) found a significant association between psychedelic-catalysed insight and therapeutic outcomes. Of the 8 RCTs that examined the relationship between psychedelic-catalysed insight and therapeutic outcomes, 6 (75%) found a significant relationship. Across other study types, 19 of 21 studies (90%) found at least some therapeutic outcomes were associated with insight ratings. These associations were found across therapeutic outcomes, including psychopathology symptoms (such as depression, drug and alcohol use problems, obsessions and compulsions, and trauma symptoms), psychopathology processes (such as thought suppression, experiential avoidance, and rumination), global measures of mental health (such as wellbeing and satisfaction in life) and health-associated outcomes (such as psychological flexibility, self-compassion, and various health behaviours). More studies presented data correlating insight with psychopathology outcome measures (n = 11) than with positive mental health outcome measures (n = 6). Pooled correlations, calculated via a random-effects model, were similar for both psychopathology (r = -0.33, 95% CI, I 2 = 73%) and positive mental health outcomes (r = 0.43, 95% CI [0.24, 0.58], I 2 = 76%). These findings may overstate the relationship between insight and mental health outcomes due to publication bias and the J o u r n a l P r e -p r o o f selective reporting of significant associations, as insight was typically not a primary outcome in the included studies. Nonetheless, the evidence from clinical trials to date, while preliminary, suggests that the intensity of acute psychedelic-catalysed insight is associated with improved therapeutic outcomes, including reduced symptomatology and increased quality of life. Of the 22 studies that measured associations between therapeutic outcomes and both insight and mystical-type experiences (including measures of key aspects of mystical-type experiences, such as ego-dissolution), 12 (55%) found that therapeutic outcomes were more strongly associated with acute insight than mystical-type experiences. Five studies (23%) found that mystical-type experiences were more strongly associated with therapeutic outcomes than insight measures were, while another five studies (23%) reported mixed results. Steiger z-testswere applied to 15 comparisons of correlations with therapeutic outcomes from nine studies, revealing that 7 comparisons favoured insight, 8 showed no difference, and none favoured mystical-type experiences. Interestingly, when looking at associations with increases in certain positive mental health outcomes (such as wellbeing and satisfaction with life), 4 of 8 studies (50%) found that these outcomes were more strongly associated with mystical-type experience than insight, while only 3 of 8 studies (38%) favoured insight. Whether insight and mystical-type experiences better predict different types of outcomes, will be an interesting question for future research. The interpretation of comparisons between insight and mystical-type experiences is complicated by the inclusion insight-related items in measures of mystical-type experience, such as the Mystical Experience Questionnaire and Hood Mysticism Scale. In particular, items within the Noetic Quality factor of mystical experience measures overlap conceptually with insight. The relationship between, and disentangling of, insight and mystical experiences both complex, multidimensional constructswarrants further research. However, the J o u r n a l P r e -p r o o f present finding that psychedelic-catalysed insight more reliably predicts therapeutic improvements than mystical-type experiences, suggests that a narrow focus on mystical-type experiences as a therapeutic goal or as a proxy measure treatment success, may be misguided. Instead, the practice and assessment of psychedelic-therapy should consider a broader variety of psychedelic experiences, such as those primarily characterised by insight.
While these provide support for insight as a central and therapeutic component of the psychedelic experience, they should be interpreted with caution and further explored in future research. The findings, and especially interpretations of their synthesis, are limited by the diversity of included study designs and timing of survey administration, and by the heterogenous ways in which insight is operationalised in existing measures. In broad measures of altered states of consciousness, such as the 11-Dimension Altered States of Consciousness Rating Scale (11D-ASC) and the Mystical Experience Questionnaire (MEQ43), the insight-related factors capture select aspects of the phenomenology of insight. For example, the 11D-ASC Insightfulness factor captures profundity ("I felt very profound") and originality ("I had very original thoughts"), while the MEQ43 Noetic Quality factor captures certainty ("Certainty of encounter with ultimate reality [in the sense of being able to "know" and "see" what is really real] at some time during your session") and an intuitive rather than analytical basis for insight ("Gain of insightful knowledge experienced at an intuitive level"). In contrast, the recently developed measures assessing the subset of insights considered psychologically-relevant, the Psychological Insight Scaleand Psychological Insight Questionnaire, capture only insight content but not phenomenology. Given the heterogeneity of the data available, we did not attempt to quantitatively synthesise findings through meta-analysis.
The operationalisation of insight in existing measures is not just heterogeneous, but incomplete, potentially leading this review to overlook aspects of psychedelic-catalysed insight that may be important for therapeutic outcomes. No existing measures currently capture the full range of commonly reported psychedelic-catalysed insight content, including mystical, psychological, and other themes. Further no measures capture all the phenomenological qualities commonly used in cognitive science to identify insight, such as suddenness, certainty, surprise and emotionality. Additionally, there may be other factors important to the study of psychedelic-catalysed insight that are not currently prominent in the insight or psychedelic literatures, such as the attributed source of insights (e.g., insights received from other entities), the novelty of the insight, or the degree to which an insight fits with or demands a change in the person's worldview. Future research should seek to identify and assess the therapeutically relevant aspects of psychedelic-catalysed insight, through both qualitative investigations and the development of more comprehensive psychometric instruments. Other limitations of the review process include that we dually screened only a subsample of studies, and did not formal assess publication bias. Findings on the relationship between insight and mental health outcomes, in particular, may overstate the strength of the relationship due to publication bias and selective reporting, given that insight was typically not a primary outcome of the included studies. Additionally, most included studies were subject to methodological limitations (e.g., lack of placebo control, inadequate blinding, small sample sizes). Even in well-designed clinical trials, strong correlations between clinical outcomes and aspects of the acute psychedelic experience do not provide evidence for causal claims, leaving open epiphenomenal and other accounts. Various research approaches are being sought to clarify the role of subjective experience in the therapeutic effects of psychedelics, including the administration of psychedelics to people under J o u r n a l P r e -p r o o f anaesthesia, and the development of psychedelic-like drugs designed to have minimal subjective effects. Similarly, more robust support for the causal role of psychedelic-catalysed insight in therapeutic benefit, will require studies that go beyond associating therapeutic outcomes with the degree of acute insightfulness experienced. Studies demonstrating a clear link between the specific contents of psychedelic-catalysed insight and related positive behavioural changes, would provide stronger evidence for insight as a therapeutic mechanism. Such a relationship was found in an open-label trial of psilocybin therapy for tobacco addiction, where seven of the 12 participants reported that the contents of psilocybin-catalysed insights that were directly relevant to their efforts to quit smoking. Future research should seek to replicate and extend these findings. Despite our finding that psychedelic-catalysed insight predicts positive outcomes, insight experiences can be misleading or maladaptive, despite feeling true. While insight experiences are associated with more accurate problem-solving, they can also be misleadingand bias epistemic processes. For example,found that participants rated worldview beliefs as truer when they had just experienced an insight while solving an anagram corresponding to the belief. Also, insight experiences have long been linked to psychosis, where they have been proposed to play a central role in its onset via a series of insight experiences and contradictory or undermining "anti-aha experiences" that can cause profound and enduring destabilisation. Even in the absence of psychopathology, insight experiences can have negative effects. For example, Timmerman and colleagues (2020) describe a trial participant who experienced significant distress after being J o u r n a l P r e -p r o o f unable to determine the veracity of a revelation that his parent had tried to smother him as an infant. The risks associated with misleading insights are exacerbated by the tendency of understandings arrived at via insight to be more resistant to disconfirmatory evidence. Further research is necessary to characterise the range, prevalence, and early indicators of epistemic harms, which could inform clinical practice in working with insights to increase the probability that they are useful and adaptive. Additionally, drawing on other fields which work with unfalsifiable experiences, such as recovered memories in therapy and particular adverse effects in meditation, could be valuable for clinicians supporting people who are at risk of a maladaptive interpretations following insight experiences.
As a follow-up to this review, several directions are recommended for future research.
In this first systematic review on psychedelic-catalysed insight, we used a systematic search approach to collate a comprehensive list of all relevant studies and data ever published. Here, we examined psychedelic-catalysed insight and its prevalence, relationship to psychedelic dose, time-course and relationship to therapeutic efficacy. Insight was common at psychoactive doses, and the intensity of insight experiences was positively correlated with dose. Preliminary evidence suggested that psychedelic-catalysed insight tend to be rated as genuinely insightful even years after the experience. Of greatest clinical relevance, insight was positively associated with therapeutic benefits following psychedelics. This relationship was seen across different substances, study designs, populations, and constructs. Notably, the relationship between therapeutic benefit and insight was typically stronger than with mystical-type experience. These findings suggest that future studies of psychedelic-catalysed insight could valuably inform both clinical practice of psychedelic therapies, and understanding of the mechanisms of psychedelic therapeutic efficacy. Healthcare Ltd, the Scientific Advisory Board of the MIND Foundation, and a co-founder of Clarion Clinics. These organisations were not involved in any aspect of this paper, including the decision to write it, drafting the paper, or its publication.
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