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Nonadherence to medication remains a challenging problem in the management of patients suffering from schizophrenia. Studies on the association between the severity of schizophrenia symptoms and lack of insight into medication adherence have yielded conflicting results. Very few studies have been conducted on Egyptian patients with schizophrenia to determine the impact of these factors on medication adherence.The aim of this study was to identify the clinical features of schizophrenia that correlate with nonadherence to medication.This is a prospective study in which 109 patients were recruited from Ain Shams University, Institute of Psychiatry. Patients were interviewed initially using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV), Axis I Diagnosis Clinical Version and the Positive and Negative Syndrome Scale (PANSS). Six months later, the patients were reassessed with PANSS, the Brief Adherence Rating scale, and the Scale to Assess Unawareness of Medical Disorder.Two-thirds (68.8%) of the studied patients were nonadherent and only one-third (31.2%) were adherent, according to the Brief Adherence Rating scale. It was found that the majority of adherent patients (61.8%) were insightful, whereas most of the nonadherent patients (94.7%) were insightless, with highly significant statistical difference. Severity of illness was found to be significantly higher at the beginning of the study compared with that at the time of reassessment. The comparison of PANSS scores in adherent versus nonadherent patients revealed a highly significant statistical difference, with lower mean scores in total and all subscales of PANSS in adherent patients. Finally, logistic regression analysis was performed to evaluate the predictive factors for nonadherence, which revealed that more severely ill patients were less compliant with medication and insightful patients were significantly more compliant.Medication nonadherence is considered a highly prevalent problem among Egyptian patients with schizophrenia. The present study supported earlier findings in Western countries on the role of insight and illness severity in medication nonadherence among schizophrenic patients. Thus, it is mandatory to assess patients’ insight and implement various interventions to improve it very early in the management plan.