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In legal proceedings, being fit to stand trial is the opposite of insanity. Pleading not guilty for insanity suggests a chronic mental health issue that leaves the person incapable of understanding or making sound judgements.
We have a similar system in place in the medical field. If a person is unable to demonstrate basic self awareness in the moment, they cannot consent to medical care. For us, this means implied consent takes effect and we are allowed to act in what would be considered a reasonable manner to save the patients life. There are systems in place for people who are chronically not oriented; be it medical power of attorney, advanced directives, DNRs, etc
From what I understand, this is (in spirit at least) what's happening in a legal setting as well. If a person isn't capable of understanding the legal proceedings, then they need to be treated for their illness before the case can continue. I could be misremembering but a not guilty verdict by reason of insanity isn't a get out of jail free card, it's a "go to a state run mental institution until you're able to stand trial" card. You're still being locked up, often times into an environment that is significantly worse than the prison you would've gone to instead. Possibly for longer than the sentence they would've (and still may) served in prison. It's an awful system with massive flaws that punishes some of the most disadvantaged people in society for being neglected by the state to a point where they're a danger to themselves and those around them.
Insanity defense means you were insane at the time of the crime. Fit to stand trial means your ability to comprehend the trial as the trial happens. They are separate things in a temporal sense.
It can be an acute condition as well, only affecting the defendant at the time of the crime.
From Wikipedia:
Ohio Supreme Court also has something: